CANNOT LEAVE THE LIBRARY. 

m ^ 






CHAP..-±i-i^: 
g Shelf- 



COPYRIGHT DEPOSIT. 

w. 

LIBRARY OF CONGRESS. | 



A TREATISE 



DISEASES 



IMANCY AND CHILDHOOD, 



J. LEWIS SMITH, M.D., 

PHYSICIAN TO THE NEW YORK INFANTS' HOSPITAL ; PHYSICIAN TO THE CATHOLIC FOUNDLING 

ASYLUM ; PHYSICIAN TO THE PROTESTANT INFANT ASYLUM ; CONSULTING PHYSICIAN 

TO THE CLASS OF CHILDREN'S DISEASES, OUT-DOOR DEPARTMENT OF 

EELLEVUE HOSPITAL ; CLINICAL LECTURER ON DISEASES 

OF CHILDREN IN EELLEVUE HOSPITAL 

MEDICAL COLLEGE. 



THIKD EDITION, 

NLARGED ANB THOROUGHLY REVISED. 

WITH ILLUSTRATIONS. 




PHILADELPHIA: 

H ^E N R Y C. LEA. 

18 76. 




Entered according to Act of Congress, in the year 1875, 

By henry C. lea, 

In the office of the Librarian of Congress, at Washington, D. C. 
[ All rights reserved. ] 



SHERMAN it CO., PRINTERS, PHILADELPHIA. 



PEEFACE TO THE THIHD EDITION. 



The present edition is considerably enlarged. Several important 
diseases, which were omitted from the former editions, are treated at 
length in this, and in order to bring the treatise up to our present 
knowledge, it has been necessary to rewrite and enlarge a considerable 
part of the text. The additions thus made, though considerable, have 
been accommodated by an increase in the size of the page and a change 
in the type employed. 

The author has endeavored to make the treatise practical, and has, 
he believes, recommended only such modes of treatment as are based 
on a sound and established pathology, and have been sufl&ciently tested 
by experience. The large institutions of New York in which children 
are treated, with several of which the author has an official connection, 
have given him unusual facilities for clinical study, so that he is 
enabled to state his views with greater precision and positiveness 
than would be possible without such a field for observation. 

Among the diseases now considered for the first time are Rdtheln 
and Cerebro-Spinal Fever, epidemics of which have occurred in New 
York since the appearance of the last edition. Diphtheria has 
become a disease of great importance in this country, desolating 
many families, my own among others, and snatching away many a 
child of bright promise. Although of late the profession 'has ac- 
quired a greater insight into the nature of this disease than we for- 
merly possessed, and we arc able to trea( more successfully its local 
manifestations, nevertheless, there are cases, and not a few, \vhich are 



IV PREFACE TO THE THIRD EDITION. 

attended by early and profound blood poisoning, and are but par- 
tially amenable to treatment, which still renders diphtheria the 
most fatal disease of childhood in the localities where it prevails. 
Indeed, there is no infectious disease which involves greater danger, 
and in which there are so many modes of death. Nearly the 
entire article relating to this important malady has been rewritten, 
as have also been several other chapters. 

227 West Forty-ninth Strekt, New York, 
December, 1875. 



PEEFACE TO THE SECOND EDITION. 



The purpose of the author has been to present a description of the 
diseases of infancy and childhood succinctly, but at the same time in a 
sufficiently comprehensive manner to meet the requirements of the 
medical student and practitioner. He has endeavored to incorporate 
in the treatise all recently ascertained facts relating to this branch of 
medical practice, and especially has it been Jiis endeavor to recommend 
such modes of treatment as comport with and are suggested by our 
present knowledge of the pathology of early life, the efficacy of hy- 
gienic measures in the treatment of the young, and the recuperative 
powers of the system at this age. 

While the author has respected the opinions of previous writers, 
and has adopted them, so far as they appeared to be correct, he has 
depended much more for the material of his treatise on clinical observ- 
ations and the inspection of the cadaver. Necessarily, as a result of 
independent investigations, opinions are now and then expressed differ- 
ent from those which are commonly accepted. Novel views have not, 
however, been presented, unless the author was fully satisfied that they 
were substantiated by a sufficieut number of observations. 

In presenting to the profession the second edition of his work, the 
autlior gratefully acknowledges the favorable reception accorded to the 
first. He has endeavored to merit a continuance of this approbation 
by rendering the volume much more complete than before. Nearly 
twenty additional diseases have been treated of, among which may be 
named Diseases Incidental to Birth, Rachitis, Tidjercnlosis, Scrofula, 



VI PREFACE TO THE SECOND EDITION. 

Intermittent, Remittent, and Typhoid Fevers, Chorea, and the various 
forms of Paralysis. Many new formuke, which experience has shown 
to be useful, have been introduced, portions of the text of a less prac- 
tical nature have been condensed, and other portions, especially those 
relating to pathological histology, have been rewritten to correspond 
with recent discoveries. Every effort has been made, however, to 
avoid an undue enlargement of the volume, but, notwithstanding this, 
and an increase in the size of the i)age, the number of pages has been 
enlarged by more than one hundred. 

227 West Forty-ninth Street, New Yokk, 
April, 1872. 



CONTENTS. 



PART I. 

CHAPTER I. 

PAGE 

Infancy ani> Childhood, 17 

CHAPTEE II. 
Care OF THE Mother IN Pregnancy, 19 



CHAPTER III. 

Mortality of Early Life — its Causes and Prevention, ... 22 

CHAPTER IV. 

Lactation, 28 

Hindrances to Lactation, and phj'sical conditions rendering it Improper 
— Facts and Rules in reference to Lactation — Human Milic — -Modifica- 
tions of the Milk in consequence of the Diet — Modification of Milk from 
its retention in the Breast — Modification of Milk by Age and by Mental 
Impressions — Modification of Milk by the Catamenial Function and 
Pregnancy — Quantity of Breast-milk required by the Infant — Difi"er- 
ences in Suckling "Women as regards Quantity and Quality of Milk — 
Scantiness of Milk ; its Causes and Treatment. 

CHAPTER V. 

Selection of a Wet-Nurse, 47 

CHAPTER VI. 

Course of Lactation — Weaning, 60 

CHAPTER VII. 
Artificial Feeding, 52 

Composition of milk. 

CHAPTER Vin. 
Baths— Clothing, 58 



Vni CONTENTS. 

CHAPTER IX. 

PAGE 

Accidents and Atlmknts incidental to the Birth of the Infant, and 

Detachment of the Cord, 59 

Apncea (Asphyxia) Neonatorum — Causes — Treatment — Caput Succeda- 
neum — Cephalajmatoma. 

CHAPTER X. 
Conjunctivitis Neonatorum, 62 

Cases — Symptoms — Treatment. 

CHAPTER XI. 

Diseases of the Umbilicus, 66 

Inflammation of the Umbilical Vein and Arteries — Treatment — Inflam- 
mation and Ulceration of Umbilicus — Treatment — Umbilical Granula- 
tions or Fungus — Treatment. 

CHAPTER XII. 
Umbilical Hemorrhage, 68 

Sex — Age — Causes — Symptoms — Prognosis — Treatment. 

CHAPTER XIII. 

Diagnosis of Infantile Diseases, 72 

General Observations — Features, External Appearance of Head, Trunk, 
and Limbs in Disease — Attitude — Movements— The Voice — Respiratory 
System — Respiration in Health — Respiration in Disease — Circulatory 
System — Pulse in Health— Pulse in Disease— Animal Heat — Digestive 
System — Nervous System, Pain. 



PART 11. 

CONSTITUTIONAL DISEASES. 

SECTION I. 
DIxlTHETIC DISEASES. 

CHAPTER I. 
Rachitis, 85 

Age — Anatomical Characters— Craniotabes— Symptoms — Complications 
— Diagnosis — Prognosis — Treatment. 

CHAPTER II. 

Scrofula, 97 

Causes — Anatomical Characters — Symj)toms — Relation of Scrofula to 
Tuberculosis — Prognosis — Treatment: Prophylactic ; Curative. 



CONTENTS. 



CHAPTER III. 

PAGE 

Tuberculosis, 112 

Etiology — General Anatomical Characters of Tuberculosis — Anatomical 
Characters in Infancy and Childhood — Lungs — Abdominal Viscera — 
Stomach and Intestines — Symptoms — Bronchial Clands — Physical 
Signs — Lungs — Pleura — Stomach and Intestines — Diagnosis — Prog- 
nosis — Treatment : Prophylactic ; Curative. 

CHAPTER IV. 
Syphilis, 136 

Etiology — Clinical History — Manifestations — Coryza — Mucous Patches 
— Roseola — Pemphigus — Acne, Impetigo, and Ecthyma — Visceral Le- 
sions — Osseous Lesions — Prognosis — Treatment. 



SECTION II. 
EEUPTIYE FEYEES. 

CHAPTER I. 
Measles, . 147 

Symptoms^Complications : Capillary Bronchitis, True Croup, Pneu- 
monitis — Anatomical Characters — Nature — Diagnosis — Prognosis — ■ 
Treatment. 

CHAPTER II. 
Scarlet Fever, 156 

Symptoms, Regular Eorm ; Irregular Form ; Malignant Form — Com- 
plications : Gangrene of the Mouth, Articular Rheumatism, Serous In- 
flammation — Sequels: Nephritis, Otorrhoga — A Case — Anatomical 
Characters — Nature — Diagnosis — Prognosis — Treatment — Prophylaxis. 

CHAPTER III. 

ROTHELN, 184 

Premonitory Stage — Symptoms — Tegumentary System — Skin — Mucous 
Membrane — Pulse — Temperature — Respiratory System — Digestive Sys- 
tem — Complications — Prognosis — Nature. 

CHAPTER IV. 
Variola — Varioloid, 192 

Incubative Period — Stage of Invasion— Stage of Eruption — Stage of 
Desiccation — Desquamation — Varioloid — Mode of Death — Anatomical 
Characters — Comjilications — Prognosis — Diagnosis — Treatment. 

CHAPTER V. 

Vaccinia, 202 

History of Vaccination — Apjjearancos, Symptoms, Anomalies, Compli- 
cations, and Sequels — Subsequent Vaccinations — I'l'otectiun from Vacci- 
nation — Revaccination — Selection of Virus. 



X CONTENTS. 



CHAPTER VI. 

PAGE 

Varicella, 212 

Incubative Period — Symptoms— Diagnosis — Prognosis — Treatment. 



SECTION III. 
NOK-ERUPTIYE CONTAGIOUS DISEASES. 

CHAPTER I. 
Diphthp:ria, 215 

Age — Incubation — Nature — Causes — Anatomical Characters — Symp- 
toms — Sequelae — Prognosis — Diagnosis — Treatment : Preventive Meas- 
ures. 

CHAPTER II. 

Pertussis, 246 

Symptoms — Second Period — C<mi plications — Convulsions — Bronchitis — 
Pneumonitis — Thrombosis — Dijignosis — Prognosis — Treatment. 

CHAPTER III. 
Parotiditis, 258 

Nature — Diagnosis — Treatment. 

SECTION IV. 
OTHEK GENERAL DISEASES. 

CHAPTER I. 
Intermittent Fever, 261 

Symptoms — Prognosis — Treatment. 

CHAPTER II. 

Remittent Fever, 266 

Symptoms — Diagnosis — Treatment. 

CHAPTER III. 

Typhoid Fkver, 268 

Causes — Anatomical Characters — Symjitoms — Complications — Diagnosis 
— Duration — Prognosis — Treatment. 

CHAPTER IV. 
Cerebro-Spinal Fever, 275 

Cause— Sex — Age — Symptoms — Mode of Commencement — Symptoms 
pertaining to the Nervous System— Digestive System — Pulse — Tempera- 
ture — Respiratory System — Cutaneous Surface — Nature— Prognosis — 
Diagnosis — Anatomical Characters — Treatment — Preventive — Curative. 



CONTENTS. 



CHAPTER V. 

PAGE 

Acute Rheumatism, 306 

Causes — Symptoms — Duration — Prognosis — Diagnosis — Treatment. 

CHAPTER VI. 

Erysipelas, 312 

Table of Cases — Age — Point of Commencement — Causes — Premonitory 
Symptoms — Symptoms — Prognosis — Duration — Modes of Death — Patho- 
logical Anatomy — Treatment. 



PAET III. 

SECTION I. 

DISEASES OP THE CEREBRO-SPINAL SYSTEM, . 321 

CHAPTER I. 
AcEPHALUS — Anencephalus, 323 

Anatomical Characters — Symptoms — Prognosis. 

CHAPTER II. 
Imperfect Brain, 326 

A Case — Symptoms — Prognosis — Microeephalus — Atrophy of Brain. 

CHAPTER III. 
Hypertrophy of Brain, 328 

Pathological Anatomy — Causes — Cretinism — Symptoms — A Case — Diag- 
nosis — Prognosis — Treatment. 

CHAPTER IV. 

Thrombosis in the Cranial Sinuses (Phlebitis), 333 

Anatomical Characters — Causes; from Otitis — Symptoms — Diagnosis — 
Prognosis — Treatment. 

CHAPTER V. 

Congestion of Brain, 337 

Causes — Symptoms — Anatomical Characters — Prognosis — Treatment. 

CHAPTER VI. 

InTRA-CrANIAL H/EMORRIIAGK (MeNIXQICAL HyEMORRHAGE — CEREBRAL 

HiEMOKRIIAOE), 342 

Causes — Anatomical Characters — Synii)t<iins — Diagnosis — Prognosis — 
Treatment. 



Xll CONTENTS. 



CHAPTER VII. 

PAGE 

Congenital Hydrocephalus, 352 

Anatomical Characters — Symptoms — Diagnosis — Prognosis — Treatment. 

CHAPTER YIII. 

Acquired Hydrocephalus, 359 

Causes — Amitomical Characters — Location and Quantity of Fluid — 
Symptoms — Prognosis — Treatment. 

CHAPTER IX. 

Meninqitis, Simple and Tubercular, 362 

Age — Anatomical Characters — Causes — Premonitory Stage— Symptoms 
— A Case — Diagnosis — Prognosis — Treatment. 

CHAPTER X. 

Spubious Hydkocephalus, 380 

Anatomical Characters — Symptoms — Cases — Diagnosis — Prognosis — 
Treatment. 

CHAPTER XI. 

Eclampsia, 386 

Essential, Symptomatic, Sympathetic — Causes — Premonitory Stage — 
Symptoms — Anatomical Characters— Diagnosis— Prognosis — Treatment. 

CHAPTER XII. 

Tetan-us Infantum, 397 

Table of Cases — Period of Commencement — Frequency in Certain Local- 
ities — Cases — Symptoms — Mode of Death — Prognosis — Duration in Fatal 
Cases — Duration in Favorable Cases — Diagnosis — Preventive Treatment 
^Treatment. 

CHAPTER XIII. 

Internal Convulsions, 417 

Different Forms — Causes — Anatomical Characters — Symptoms — Case — 
Diagnosis— Prognosis — Modes of Death — Treatment. 

CHAPTER XIV. 
Chorea , 426 

Age — Causes — Sex — Uterine Irritation — Ansemia — Rheumatism — 
Fright — Imitation — Intestinal Irritation — Lesions of Brain and Spinal 
Cord — Anfttomical Characters — Symptoms — Prognosis — Course — Diag- 
nosis — Treatment: Regimenal; Medicinal. 

CHAPTER XV. 

Infantile Paralysis, 440 

Symptoms — Prognosis— Progress— Etiology— Anatomical Cliaracters— 
Diagnosis— Prognosis — Treatment. 



CONTENTS. XIU 

CHAPTER XVI. 

PAGE 

Facial Paralysis, 451 

Causes — Symptoms — Prognosis — -Treatment. Paralysis with Pseudo- 
Hypertrophy : Symptoms — Anatomical Characters — Causes — Prognosis 
— Treatment. 

CHAPTER XVII. 

Diseases or THE Spinal CoKD AND ITS Coverings, 456 

Congestion of the Spinal Cord and its Membranes — Anatomical Charac- 
ters — Symptoms — Treatment. 

CHAPTER XVIII. 

Spina Bifida, . , 460 

Diagnosis — Prognosis — Treatment. 

CHAPTER XIX. 

Vertebral Caries, ............ 464 

Causes — Symptoms — Diagnosis — Prognosis — Treatment.. 



SECTION II. 

DISEASES OF THE EESPIEATOET SYSTEM. 

CHAPTER I. 
CORYZA, 469 

Causes — Anatomical Characters — Symptoms — Prognosis — Treatment. 

CHAPTER IL 

Simple Laryngitis, 472 

Symptoms — Chronic Form — Anatomical Characters — Treatment. Spas- 
modic Laryngitis: Causes — Symptoms — ^Anatomical Characters — Pathol- 
ogy — Diagnosis — Prognosis— Treatment. 

CHAPTER III. 

Pseudo-Membranous Laryngitis, 481 

Causes — Anatomical Characters — Symptoms — Pathological Characters — 
Diagnosis — Prognosis — Treatment — Tracheotomy. 

CHAPTER IV. 

Bronchitis, 497 

Causes — Anatomical Characters — Symptoms — Capillar}' Bronchitis — 
Diagnosis— Prognosis — Treatment. 

CHAPTER V. 

Atelectasis, .509 

Symptoms — Anatomical Characters — Treatment. 



CONTENTS. 



CHAPTER VI. 

PAGE 

Pneumonitis, 513 

Catarrhal, Croupous, and Interstitial — Causes — Hypostasis — Anatomical 
Characters — Cheesj'^ Pneumonitis — Symptoms — Physical Signs — Diag- 
nosis — Prognosis — Treatment. 

CHAPTER VII. 

Pleuritis, 528 

Causes — Cases — Anatomical Characters — Empyema — Symptoms — Phys- 
ical Signs : Auscultation — Percussion — Inspection — Mensuration — Case 
— Diagnosis — Prognosis — Treatment — Thoracentesis — Nervous Cough — 
Treatment. 



SECTION III. 
DISEASES OF THE DIGESTIVE APPAEATUS. 

CHAPTER I. 

Simple Stomatitis; Ulcerous Stomatitis ; Follicular Stomatitis, . 552 
Simple or Erythematic Stomatitis: Causes — Symptoms — Appearances — 
Treatment. Ulcerous Stomatitis: Anatomical Characters — Causes — 
Symptoms — Prognosis — Treatment. Follicular Stomatitis : Anatomical 
Characters — Causes — Symptoms — Diagnosis — Prognosis — Treatment. 

CHAPTER II. 
Thrush, 559 

Anatomical Characters — Description of the Oicliura Albicans — Symp- 
toms — Causes — Diagnosis — Prognosis — Treatment. 

CHAPTER III, 

Gangrene of the Mouth, 563 

Anatomical Characters — Age — Causes — Symptoms — Diagnosis —Prog- 
nosis — Treatment. 

CHAPTER IV. 

Dentition, 570 

Pathological Results of Dentition — Diagnosis — Treatment — Scarification 
of the Gums — Second Dentition. 

CHAPTER V. 

Simple Pharyngitis ; Peri-Pharyngeal Abscess ; OiIsophagitis, . . 578 

Pharyngitis : Anatomical Characters — Causes — Symptoms — Prognosis — 
Diagnosis — Treatment. Peri-Pharyngeal Abscess: Age — Cause — Ana- 
tomical Characters — Symptoms — Duration — Diagnosis — Prognosis — 
Treatment. (Esophagitis : Anatomical Characters — Treatment. 



CONTENTS. 



CHAPTER VI. 



Indigestion ; Congestion of Stomach ; Gastritis ; Follicular Gas- 
tritis; Diphtheritic Gastritis; Post-mortem Digestion; Soften- 
ing, 589 

Indigestion : Causes — S3'mptoms — Prognosis — Treatment. Congestion 
of the Stomach. Gastritis: Causes — Age — Sjnnptoms — Anatomical 
Characters — Diagnosis — Prognosis — Treatment. Follicular Gastritis; 
Diphtheritic Gastritis; Post-mortem Digestion; Softening; White 
Softening. 

CHAPTER VII. 

DiARRHCEA, . 605 

Non-Inflammatorj- Diarrhoea: Causes — Symptoms — Anatomical Char- 
acters — Diagnosis — Prognosis— Treatment. 

CHAPTER VIII. 

Intestinal Inflammation of Infancy, 611 

Causes — Age — Symptoms — Microscopic Character of the Stools — Pulse 
— Anatomical Characters — Condition of the Liver — State of the Brain 
— Diagnosis— Prognosis — Treatment, Regimenal Measures, Medicinal 
Treatment; Enemata, External Treatment. 

CHAPTER IX. 

Enteritis and Colitis in Childhood, 634 

Causes — Symptoms — Diagnosis — Prognosis — Treatment. 

CHAPTER X. 

Cholera Infantum, 637 

Definition of the Term — Causes — Its Prevalence in the Cities — Symp- 
toms — Anatomical Characters — Diagnosis — Prognosis — Treatment. 

CHAPTER XI. 

Intestinal Worms, 645 

Five Kinds — Description of them — Causes — Symptoms of Lumbrici — 
Diagnosis — Prognosis — Treatment — Use of Santonin, Spigelia, Cheno- 
podium. 

CHAPTER XII. 

Gastro-Intestinal haemorrhage, 656 

Three Varieties — Causes — Prognosis — Treatment. 

CHAPTER XIII. 

Intussusception, . 661 

Intussusception without Symptoms — Intussusception with Symptoms — 
Previous Health — Causes — Age — Seat and Pathological Anatomy — In- 
tussusception in the Small Intestines — Cases — Intussusception in the; Large 
Intestines — Sj'mptoms — Diagnosis — Duration — Prognosis — Modes of 
Death — Treatment. 



XVI CONTENTS. 

SECTION IV. 

DISEASES or THE CIRCULATOKY SYSTEM. 

CHAPTER I. 

PAGE 

Cyanosis, 683 

Literature of Cyanosis— Sex— Causes of the Malformation — Time of 
Commencement — Symptoms — Prognosis — Mode of Death — Modes of 
Compensation — Morbid Anatomy — Theories Relating to the Etiology of 
Cyanosis — Treatment. 

SECTION Y. 

SKII^ DISEASES. 

CHAPTER I. 

Erythematous Diseases, 701 

Erythema: Two Forms; Idiopathic, Symptomatic — Prognosis— Diag- 
nosis — Treatment. Roseola: Symptoms — Causes — Prognosis — Diag- 
nosis — Treatment. Urticaria : Causes — Prognosis— Diagnosis — Treat- 
ment. 

CHAPTER II. 

Papular Diseases, Strophulus, 707 

Lichen — Prurigo — Strophulus — Treatment. 

CHAPTER III. 

Eczema, 709 

Anatomy— Etiology— Varieties— Symptoms— Course— Diagnosis— Treat- 
ment— Scabies : Diagnosis — Treatment. 



INDEX, 



717 



DISEASES OF CHILDREK 



PART I. 

CHAPTER I. 

INFANCY AND CHILDHOOD. 

Infancy and childhood are in certain respects the most important and 
interesting periods of life. To the physiologist they are especially inter- 
esting, because they are the periods of development and of greatest func- 
tional activity ; to the pathologist, because in them many diseases occur 
which are rarely or never observed in the other periods, or which present 
in these periods peculiar features ; to the physician and vital statistician, 
because in them there is the greatest amount of sickness, and largest 
number of deaths. 

Infancy extends from birth to the age of two and a half years, or till 
the completion of first dentition. In infancy the organs are delicately 
organized, containing a large proportion of water, and hence are easily 
injured. In this period the brain is rapidly developed — more so than any 
other organ ; animal matter predominates in the bones ; the arteries are 
relatively large, the muscles small ; the superficial veins are small. Fat 
is absent from the interior of the body, but abundant, in well-nourished 
infants, underneath the integument. The skin is delicate, and its temper- 
ature not much below that of the blood. At birth it has a reddish hue, 
and is covered with soft fine hairs (lanugo). The reddish hue gradually 
fades into the healthy tint of infancy, and the hairs fall out. In the first 
two mouths the sweat-glands have little functional activity, sensible per- 
spiration being quite rare. Subsequently perspiration is freer, and in 
certain diseased states (rachitis, etc.) is abundant. The sebaceous glands 
in the first half of infancy are active, particularly upon the scalp, pro- 
ducing often a pale yellow incrustration, consisting of sebaceous matter 
and epidermic cells. 

The secretions from the nuicous surface?- coninieuce at an early period 



18 INFANCY AND CHILDHOOD. 

At birth the surface of the digestive tube is covered with more or less 
mucus, often iu considerable quantity. The meconium is not considered, 
as formerly, to be a product of intestinal secretion. It consists of flat epi- 
thelial cells, fine hairs, oil-globules, crystals of cholesterin, and brownish 
or yellowish masses of coloring matter, probably from the liver. It is 
supposed that, with the exception of the coloring matter, the meconium is 
derived mainly from the amniotic fluid which the foetus has swallowed. 

The most wonderful change occurring in the system at birth, through 
the exigencies of the new life, is that in the circulation. The flow of blood 
being interrupted, thrombi form in the umbilical vein, and arteries, and 
in the ductus arteriosus, and ductus venosus, and these vessels gradually 
atrophy, becoming finally shrivelled but permanent cords. I have many 
times at autopsies removed the plug from the ductus arteriosus when death 
had occurred as late as the third week. The foramen ovale closes slowly. 
I have ordinarily found it open till near the end of the first half year, but 
the valve closes fully the aperture, so that there is no detriment to the 
circulation. Both the pulse and respiration are more frequent during in- 
fancy than childhood, and are more readily accelerated by moral and 
physical causes. 

The stomach is less elongated and emesis more readily produced than 
iu the adult. The liver is large, occupying at birth nearly half of the 
abdominal cavity, but it grows smaller in successive months. The appe- 
tite is good and digestion active, so that hunger, when appeased, soon re- 
turns. The thymus gland, at birth about the size of an unexpanded lung, 
slowly atrophies, but it does not totally disappear till after infancy. 

The kidneys, distinctly lobulated at birth, gradually change their form, 
so as to present in the last part of infancy nearly the shape of the organ 
in the adult. The renal secretion commences early, even before birth. 
The kidneys seldom undergo degenerative changes as in the adult, but 
they are liable to congestions and inflammations. During the first month, 
and especially the first fortnight, crystals of uric acid, and the urates, are 
often found in the urine, in a state of apparent health, causing more or 
less fretfulness in their elimination, staining the diaper, and not infre- 
quently being arrested in the tubules of the pyramids, where they can be 
seen as pink-colored spots or lines (uric acid infarction). These deposits 
of uric acid and the urates may even occur in the foetus, producing ob- 
struction and inflammation of the renal tubes. Congenital cystic degen- 
eration of the kidneys is, in the opinion of Virchow, due to them. In 
early infancy the senses are imperfectly developed, the eyes being at- 
tracted only by bright objects, and the sense of hearing affected only by 
loud noises. Sleep is the normal state in the first weeks of life ; as the 
age of the infant increases, less and less sleep is required ; but the oldest 
infants need more than children, and several hours more than adults. 

The new-born infant is apparently destitute of mental faculties. It 



CAEE OF THE MOTHER IN PREGNANCY. 19 

the breast by instinct, and it exhibits no perception or reflection. 
The loud cries with which it commences its existence are not from anger 
or suflfering ; they appear to be normal, like the act of nursing, and prov- 
identially designed in order to expand the lungs. It is not till the close, 
or near the close, of the first month, that the gray substance of the brain 
begins to appear — the probable seat of the mind, and the source of all 
mental phenomena. Perception and curiosity are early manifested. The 
infant, as Edmund Burke has remarked, is constantly seeking new objects 
for its amusement, rejecting old playthings for such as possess more nov- 
elty. Reflection, a higher faculty of the mind, appears at a later period. 
The mind and the bodily organs in infancy are, in a high degree, impres- 
sionable. Anger is excited by trivial causes, but is easily appeased ; and 
the various functions in the system are disturbed by agencies which in 
youth or manhood would have no appreciable effect. 

Childhood extends from infancy to the age of fifteen years or puberty. 
It is a period of great physical activity, and of rapid growth. The func- 
tions of the various organs are performed with more moderation than in 
infancy, and are less frequently deranged. The volume of the brain con- 
tinues to increase rapidly, and it becomes firmer than in infancy. It is 
estimated that by the seventh year the weight of this organ has doubled. 
The mind now exerts a controlling influence over the actions of the indi- 
vidual. The digestive organs have changed, so that solid food is required. 
Most of the glandular organs are less active than in the greater part of 
infancy, and some of them, as the liver, are relatively smaller. The 
pulse and respiration gradually become less frequent as the child advances 



CHAPTEE 11. 

CAKE OF THE MOTHER IN PREGNANCY. 

The frequency of miscarriages and still-births, and the large number 
of ill-formed and puny infants, born to a precarious and short existence, 
render imperative, on the part of the mother, a strict observance of the 
laws of health, and an avoidance of all exciting or jDerturbating influ- 
ences during the time when the fcctus is being developed. The diet should 
be plain and easily digested, but nutritious. There is often a craving in 
pregnancy for unusual articles of food. These may sometimes be allowed 
within certain limits, provided that they are such as do not derange the 
stomach. Meats and animal broths, together with vegetables and farinace- 
ous food, should constitute the ordinary diet, and should be taken at reg- 
ular intervals. 



20 CARE OF THE MOTHER IN PREGNANCY. 

Daily exercise, never violent, but moderate and gentle, is requisite. 
No exercise is better, none safer and more likely to contribute to cheer- 
fulness and healthy functional activity of the organs, than the ordinary 
household duties. Lifting heavy weights, or work which, like washing 
and ironing, causes great and continued action of the abdominal muscles, 
should be avoided. Such exercise is highly injurious, and is apt to pro- 
duce premature labor. Exercise in the oj)en air, on foot or by an easy 
conveyance, conduces to the health of the mother and the growth and 
development of the foetus. On the other hand, rapid riding over rough 
roads is one of the most dangerous modes of exercise. It has been known 
to destroy the foetus, which up to that time had been apparently vigorous. 
When such a result occurs, there is probably more or less detachment of 
the placenta. 

It being a matter of the utmost importance that the health of the 
mother should continue good during gestation, any disease which she may 
have in this period, and which affects her nutrition or the character of 
her blood, should be promptly cured if practicable, and with the least 
possible reduction of the vital powers. Intermittent fever, occurring 
during gestation, should never be allowed to continue. It seriously re- 
tards foetal development, and may produce miscarriage. Unless it is 
controlled by proper measures, the offspring, though born at term, is puny 
and emaciated. Syphilis, in the pregnant woman, also requires treat- 
ment. This disease, readily transmitted from the mother to the foetus 
through the ovum or the uterine circulation, may be eradicated by anti- 
syphilitic treatment of the mother, or at least so modified that the infant 
is born vigorous and healthy. 

The pregnant woman should avoid all causes of undue mental excite- 
ment. This is almost as necessary as the avoidance of great physical ex- 
ertion. There is, during pregnancy, unusual susceptibility to mental im- 
pressions, and this should be borne in mind not only by the woman herself, 
but by those who associate with her. 

Strong emotions, whether of joy, sorrow, or anger, affect primarily the 
nervous system, but indirectly most of the organs of the body. Observa- 
tions have long established the fact, that such emotions influence the state 
and functions not only of the digestive and glandular, but muscular organs, 
as the heart and uterus. Physicians are familiar with cases in which 
vivid mental impressions produced uterine contractions, and even miscar- 
riage, or have disturbed the cataraenial function. Therefore, the associ- 
ations and cares of pregnant women should be such as conduce to cheer- 
fulness and equanimity. 

It is the popular belief, and the belief of many physicians, that vivid 
mental impressions sometimes have a direct effect on the development of 
the foetus. Many cases are on I'ecord in which infants were born with 
marks or deformities, corresponding in character with objects which had 



MATERNAL IMPRESSIONS. 21 

been seen and had made a strong impression on the maternal mind at some 
period of gestation. Whether the mind of the mother exerts a control- 
ling influence on the form and color of the foetus, is a subject of great in- 
terest to the psychologist as well as physiologist and physician, since it 
involves no less a question than the power and scope of the human mind. 
Violent emotions, it is admitted, may afiect directly most of the important 
organs in the system. They may derange the liver, causing jaundice, 
accelerate, or for a moment suspend the heart's action, stimulate the kid- 
neys, causing diuresis, or even the intestinal follicles, causing watery 
evacuations. But with all these organs the brain is connected by nerves 
which anatomy reveals. On the other hand, the mother and foetus have 
a distinct existence as regards their nervous systems, and even their blood. 
Still, the multitude of facts which have accumulated justify the belief 
that deformity or other abnormal development of the foetus is, sometimes, 
due to the emotions of the mother. Some of the cases related by Dr. 
"Whitehead, in his work on hereditary diseases, are very striking and diffi- 
cult to explain, on the ground of coincidence. I have met the following 
cases. An Irish woman of strong emotions and superstitions was passing 
along a street in the first months of her gestation, when she was accosted 
by a beggar, who raised her hand, destitute of thumb and fingers, and in 
"God's name" asked for alms. The woman passed on; but reflecting in 
whose name money was asked, felt that she had committed a great sin in 
refusing assistance. She returned to the place where she had met the 
beggar, and on different days, but never afterwards saw her. Harassed by 
the thought of her imaginary sin, so that for weeks, according to her state- 
ment, she was made w^retched by it, she approached her confinement. A 
female infant was born, otherwise perfect, but lacking the fingers and 
thumb of one hand. The deformed limb was on the same side, and it 
seemed to the mother to resemble precisely that of the beggar. In another 
case which I met, a very similar malformation was attributed by the 
mother of the child to an accident occurring to a near relative, which ne- 
cessitated amputation during the time of her gestation. I examined both 
of these children with defective limbs, and have no doubt of the truthful- 
ness of the parents. In May, 1868, I removed a supernumerary thumb 
from an infant, whose mother, a baker's wife, gave me the following his- 
tory : No one of the family, and no ancestor, to her knowledge, presented 
this deformity. In the early months of her gestation she sold bread from 
the counter, and nearly every day a child with double thumb came in for 
a penny roll, presenting the penny between the thumb and the finger. 
After the third month she left the bakery, but the malformation was so 
impressed upon her mind, that she was not surprised to see it rejDroduced 
in her infant. 

Professor William A. Hammond, of this city, in an interesting paper on 
the "Influence of the Maternal Mind," etc. {(Quarterly Journal of Psycho- 



22 MORTALITY OF EARLY LIFE. 

logical Medicine, Janua)y, 1868), says: "The chances of these instances, 
and others which I have mentioned, being due to coincidence, are infini- 
tesinially small, and though I am careful not to reason upon the principle 
of POST HOC, ERGO PROPTER HOC, I cannot, nor do I think any other per- 
son can, no matter how logical may be his mind, reason fairly against the 
connection of cause and effect in such cases. The correctness of the facts 
can only be questioned; if these be accepted, the probabilities are thou- 
sands of millions to one, that the relation between the phenomena is di- 
rect." Professor Dalton also says (Human Physiology), "There is now 
little room for doubt that various deformities and deficiencies of the foetus, 
conformably to the popular belief, do really originate in certain cases from 
nervous ihipressions, such as disgust, fear, or anger, experienced by the 
mother." The observations on which this belief is based relate both to 
man and the lower animals. A very strong argument in its support is, as 
Professor Hammond remarks, the popular opinion, which dates back to 
the time of Jacob (Genesis xxx). An almost universal sentiment, running 
through centuries, is rarelly wholly fallacious. It has some truth for its 
foundation, especially when, as in this instance, the subject is one of ob- 
servation. 

If maternal emotions affect the development of the exterior of the foetus, 
as observations show, and physiologists admit, the presumption is strong, 
that they may affect also the proper development and adjustment of the 
parts of the brain, an organ so complex and delicate, and may therefore 
give rise to idiocy. Dr. Seguin (Idiocy and its Treatment, etc., New York, 
1866) thus remarks on this point : " Impressions will, sometimes, reach the 
foetus, in its recess, cut off its legs or arms, or inflict large flesh wounds, be- 
fore birth, . . . from which we surmise that idiocy holds unknown though 
certain relations to maternal impressions, as modifications to placental 
nutrition." 

In view' of such important facts, the duty of the pregnant woman is 
rendered the more imperative to avoid the presence of disagreeable and 
unsightly objects, as well as all causes of excitement, and to remove, as 
soon as possible, vivid and unpleasant impressions, by quiet diversion of 
the mind. 



CHAPTER III. 

MOETALITY OP EARLY LIFE— ITS CAUSES AND PREVENTION. 

No fact is better known in the profession, than that the first years of 
life constitute the period of greatest mortality. 
. In England, where there is an accurate registration of births and deaths. 



CAUSES OF INFANTILE MORTALITY. 23 

statistics show fifteen deaths in every hundred infants in the first year of 
life, and between four and five deaths in the first month. Statistics on the 
continent correspond with those in England, as regards the periods of 
greatest mortality. Quetelet says, . . . . " There die during the first 
month after birth, four times as many children as during the second month 
after birth, and almost as many as during the entirety of the two years that 
follow the first year, although even then the mortality is high. The tables 
of mortality prove, in fact, that one-tenth of children born, die before the 
first month has been completed." 

In this country, in consequence of deficient registration of births, the 
percentage of deaths to births cannot be accurately ascertained. In this 
city, 53 per cent, of the total number of deaths occur under the age of five 
years, and 26 per cent, under the age of one year. According to the census 
of 1865, there were in New York city 95,020 children under the age of five 
years, and during the five years ending with 1865, 49,000 children five 
years old and under had died. Therefore, according to these statistics, 
more than one-third of all the infants born in this city die under the age 
of five years. An error, however, occurs from the fact that, while the 
death statistics were complete, it is known there were more children in the 
city than were embraced in the census returns. Still it may, I think, be 
safely stated that one-fourth of the children born in this city die before the 
age of five years. 

In less crowded cities and the rural districts, it is known that the per- 
centage of deaths in the first years of life to the total number of deaths is 
considerably less than in New York city, but it is nevertheless large. 

As the child advances towards puberty, the liability to sickness and 
death gradually diminishes, but even the last years of childhood present 
a considerably larger percentage of deaths to the population than does 
youth or manhood. 

The causes of this great mortality of infants and children, and the means 
of diminishing it, deserve careful consideration. 

Some of the causes which conspire to produce this mortality are in a 
measure unavoidable. Such are congenital vices of formation of internal 
organs. Many of the internal malformations necessarily occasion an early 
death. Cases of anencephalus, most cases of congenital hydrocephalus, of 
spina bifida, of cyanosis, are fatal before the close of infiincy. These de- 
fects of formation we cannot detect before birth, and their causes are often 
obscure. Some of them seem to result from inflammation, believed to be, 
occasionally, syphilitic, developed at some period of foetal existence. Other 
internal malformations are attributable to perturbating influences, operat- 
ing temporarily on the mother during gestation. But in a large propor- 
tion of cases, we cannot assign the cause. Obviously, only partial success 
can attend our efforts, as regards prevention in these cases, and almost no 
success, as regards the use of remedial measures. 



24 MORTALITY OF EARLY LIFE. 

Another obvious cause of the great mortality of" early life, is natural 
feebleness of system, especially in infancy. The younger the patient, prior 
to the middle period of life, the sooner are the vital powers exhausted by 
disease. Hence a larger proportion of infants succumb to the same 
malady than children, and a larger proportion of children than adults 
This statement is true of infancy and childhood in general. It is a law in 
nature, and cannot be changed by art. But there are many infants born 
with hereditary disease, or a strong predisposition to disease, through a fault, 
which is, in a degree, remediable, in the system of one or both parents, as, 
for example, the syphilitic, scrofulous, or tubercular diathesis. Parents 
seriously affected by such diseases cannot, without corrective treatment, 
have healthy offspring. Their children are among the first to droop and 
die, either directly from the inherited disease, or from feebleness of con- 
stitution, which such disease entails, and which renders them an easy prey 
to other diseases. The duty of the physician, as regards such parents, is 
obvious. He may, by therapeutic and hygienic measures, secure a more 
healthy progeny, and, so far as he can do this, he aids in diminishing the 
infantile mortality. He may sometimes, by timely measures directed to 
the infant, establish a better state of health. 

The subject of hereditary disease is one of great interest and impor- 
tance, especially as regards the city population. Inherited affections are 
less common in the country, but in the city they contribute largely to the 
number of deaths in early life. 

Another important cause of the great mortality of children, is the 
fact that they are peculiarly liable to certain severe and fatal maladies. 
I allude particularly to the acute infectious diseases, which, as a rule, 
occur but once, and that in childhood. Some of them, as scarlet fever, 
greatly increase the number of deaths. They extend and become epi- 
demic through the intercourse of children. We are constantly witness- 
ing in New York the spread of the acute contagious diseases, especially 
of hooping-cough, measles, scarlet fever, and diphtheria, through the 
schools. Measures emjiloyed, thus far, by boards of health, or other 
local authorities, to prevent the dissemination of these and kindred dis- 
eases, have accomplished but little, except in regard to small-pox. It is 
in the large public schools especially where these maladies are most fre- 
quently contracted, and from which they radiate over the school districts. 
For if, as is now common, at least in New York city, a child comes to 
school wearing clothes which at home are hanging in a room where a 
brother or sister lies sick with measles or scarlet fever ; or if he enters the 
class with a mild pertussis or diphtheria, certain of the class-mates will 
probably return home infected with the virus of the disease. The same 
remarks are applicable, though with less force, to private schools. From 
both these schools I have over and over again witnessed the dissemination 
not only of the maladies mentioned, but also of the milder infectious diseases, 



LOCALITIES AND CLEANLINESS. 25 

as mumps and varicella. Cannot boards of health or school boards do 
something more, by stringent enactments regulating the schools, to control 
this prolific source from which the infectious diseases. arise? 

In hospitals and asylums for children much can be done to prevent the 
occurrence of the infectious diseases by a strict surveillance and a prompt 
isolation of all suspicious cases. Without such care, scarcely a year passes 
in which these institutions are not scourged by one or more of these dis- 
eases. Much has been said of the crowding of families in tenement-houses 
so common in New York and other large cities, by which a large number 
of children are brought under one roof; of the uncleanliuess of person 
and apartment to which it leads, and of the insufficient air and space 
which it allows to each. But one of the strongest objections, in my opinion, 
to the present plan of building and crowding tenement-houses is the facil- 
ity which it aflx)rds to the spread of the contagious diseases of childhood ; 
and it is in such houses, as shown by statistics, that these maladies are the 
most frequent and fatal. The much-needed enactments or regulations in 
relation to the building and occupancy of such houses, would, among 
other salutary efi^ects, diminish the death-rate from those diseases to which 
we have alluded. 

Over the most loathsome, and formerly most fatal, malady of man- 
kind, namely, small-pox, we now have, or can have, complete control 
by statutory enactments, enforcing vaccination. It is only by carelessness 
or the lack of suflSciently stringent regulations relating to the matter 
that small-pox is not "stamped out." Again, some of the most fatal 
inflammatory diseases of life occur chiefly in childhood, as croup and 
capillary bronchitis. These and kindred diseases can only be prevented 
by proper hygienic management on the part of families, and books, or 
other means calculated to educate families in reference to the management 
of children, cannot fail to diminish the number of cases of such inflamma- 
tions, and consequently of the deaths from them. 

Another obvious and important cause of the mortality of early life, is 
the anti-hygienic condition or state in which many children live in conse- 
quence of the poverty or gross negligence of parents. 

Residence in insalubrious localities, personal and domiciliary uncleauli- 
ness, exposure without proper protection to vicissitudes of weather, are 
fertile causes of sickness and death. Hence one reason of the great infan- 
tile mortality among the city poor, who live in damp and dark alleys, 
and in crowded and filthy tenement-houses, breathing night and day an 
atmosphere loaded with noxious gases. All physicians are aware how 
the malignant diseases, such as Asiatic cholera, cholera infantum, diph- 
theria, and typhus fever, seek the quarters of the city poor, and what 
terrible havoc they make there. All are aware, also, what wonderful 
recoveries occur, when feeble and attenuated infants, gradually sinking 



26 MORTALITY OF EARLY LIFE. 

with clirouic disease, induced in great measure by this malaria, are trans- 
ferred from such localities to the pure air of the country. 

Careless management of young children as regards dress increases 
greatly the liability to local diseases, such as commonly occur from ex- 
posure to cold. These are inflammatory affections, seated chiefly upon 
the mucous surfaces, but sometimes in parenchymatous organs. Adults, 
aware of the effect of sudden change of temperature from warm to cold, 
or of exposure to currents of air, protect themselves by additional cloth- 
ing. Such precautionary measures are often lacking in the management 
of young children, and hence one cause of their great liability to local 
affections, both of the i-espiratory and digestive organs. 

Eouth, in his excellent treatise on Infant Feeding, says: "Among the 
most pernicious influences to young children, however, we may include 
cold ; the change of temperature from 45° to 4° or 5° below zero, as be- 
fore stated, producing an increase of mortality in London alone of three 
to five hundred. As out of one hundred deaths, however, from all speci- 
fied causes, nearly twenty-four occur to children under one, and thirty-six 
to children under five; the great increase of mortality to children by cold 
is thus at once made obvious. Indeed, it is a household word amongst us, 
which takes its origin from the Registrai'-General's returns, that a very 
cold week always increases the mortality of the very young and the very 
aged " 

Lastly, a very important c'ause of mortality in early life is the use of 
improper food. In infants, artificial feeding in place of the aliment which 
nature has provided for them, and, in children, the use of innutritions or 
indigestible articles of diet, give rise to diarrhoeal maladies, emaciation, 
and death in numerous instances. Sometimes, also, defective alimentation 
is the cause of scrofulous or tuberculous ailments, and sometimes it gives 
rise to a cachexia or feebleness of system, which, without engendering any 
positive disease, renders those thus affected less able to support disease in- 
duced by other causes. A committee, of which Prof. Austin Flint, Jr., 
was chairman, appointed in 1867 to revise the "dietary table of the Chil- 
dren's Nurseries on Randall's Island," state, with much truth and force: 
"Children .... are not capable of resisting bad alimentation, either as 
regards quantity, quality, or variety. At that age the demands of the 
system for nourishment are in excess of the waste; the extra quantity being 
required for growth and development. If the proper quantity and variety 
of food be not provided, full development cannot take place, and the 
children grow up, if they survive, into puny men and women, incapable of 
the ordinary amount of labor, and liable to diseases of various kinds." 

Improper feeding, like other causes of mortality, is much more injurious, 
much more frequently the cause of death, in the city than country. Sta- 
tistics in Europe, as well as this side of the Atlantic, establish this fact. 



IMPROPER FEEDING. 27 

It is in infancy, and especially in the first year, that the use of unwhole- 
some food entails the most serious consequences. No artificially prepared 
food is a good substitute for the mother's milk, and hence artificial feed- 
ing of the infant, unless under the most favorable circumstances, results 
disastrously. In the country, where salubrious air and sunlight conspire 
to invigorate the system, and a robust constitution is inherited, and where 
cow's milk fresh and of the best quality is readily obtained, lactation is 
not so necessary for the wellbeing of the infant; but in the city its im- 
portance cannot be too strongly urged. 

The foundlings of the cities afl^ord the most striking and convincing 
proofs of the advantage of lactation. In some cities foundlings are wet- 
nursed, while in others they are dry-nursed, and the result is always greatly 
in favor of the former. Thus, on the continent, in Lyons and Parthenay, 
where foundlings are wet-nursed almost from the time that they are re- 
ceived, the deaths are 33-7 and 35 per cent. On the other hand, in Paris, 
Rheims, and Aix, where the foundlings are wholly dry-nursed, their deaths 
are 50.3, 63.9, and 80 per cent. 

In this city the foundlings, amounting to several hundred a year, were, 
till recently, dry-nursed; and, incredible as it may appear, their mortality, 
with this mode of alimentation, nearly reached 100 per cent. Recently 
wet-nurses have been employed, for a part of the foundlings, with a much 
more favorable result. 

These facts, to which others might be added from the experience of 
European cities, show the importance of lactation as a means of reducing 
infantile mortality in the cities. What has been stated as I'egards the re- 
sult of artificial feeding of foundlings, is true, in great measure, in refer- 
ence to all city infants. The ill effect of artificial feeding is well known 
in this city, and it is the common practice in families to employ a hired 
wet-nurse, if, for any reason, the mother's milk is insufficient. 

When the infant has reached the age at which it is proper to wean it, 
the digestive organs are less frequently deranged by errors of diet. More 
substantial food, and considerable variety in it, may now be not only 
safely allowed, but are required by the wants of the system. Still, the 
feeding of children in health, and much more in sickness, is a subject of 
great importance. Therefore lactation, and the diet of infancy and child- 
hood, will occupy our attention in the following pages. 



28 LACTATION. 



CHAPTER ly. 

LACTATION". 

It is desirable that the infant, as soon as it requires nutriment, should 
receive breast-milk. If it is fed, for a few days, with the bottle or spoon, 
it may be difficult finally to induce it to take the breast; therefore it is 
well to determine early whether the mother will be able to wet-nurse her 
infant, so that, if unable, suitable provision may be made. 

The matter of determining, beforehand, the capability of the mother for 
wet-nursing has been investigated by Dr. Donne, of Paris, and in his 
treatise on Mothers and Infants he describes the mode in which it may be 
ascertained. The desired information, in his opinion, may be acquired by 
examining the colostrum, which is secreted in small quantity, in the last 
months of gestation, and which can be squeezed from the breast in suffi- 
cient quantity for inspection. 

In some women, according to Dr. Donne, the colostrum is so scanty that 
only a drop, or half a drop, can be obtained from the nipple by careful 
pressure. This will be found by the microscope to contain but few milk- 
globules, ill-formed, and a few granular bodies, such as the colostrum or- 
dinarily contains. Such women almost invariably furnish poor milk, and 
in small quantity. In other women the colostrum is abundant, but thin, 
resembling gum-water ; it lacks the yellow streaks and viscous character 
of ordinary colostrum, and it flows readily from the nipple. The milk of 
such women is sometimes scanty, sometimes abundant, but it is watery and 
deficient in nutritive principles. In a third class of women, the colostrum 
is pretty abundant, and it contains yellowish streaks, of more or less con- 
sistence, which are found to be rich in milk-globules, of good size, and 
without the admixture of mucous globules. Women furnishing such co- 
lostrum in the last weeks of gestation will have sufficient milk, and of 
good quality. These latter women make the best wet-nurses. 

Hindrances to Lactation and Physical Conditions rendering it Improper. 

The primipara often experiences difficulty in wet-nursing in consequence 
of a depressed state of the nipple. It is not sufficiently prominent to be 
readily grasped by the mouth, and after ineffectual attempts the infant 
becomes fretful when applied to the breast, and perhaps for a time refuses 
it altogether. Multiparse occasionally experience the same inconvenience, 



HINDEANCES TO LACTATION. 29 

but it is not common when there has once been successful lactation. By 
calmness and perseverance on the part of the mother, the infant can 
usually be made to seize the nipple in the course of a week. 

Depression of the nipple is, to a certain extent, the result of pressure 
upon it by the dress during gestation. The state of the nipples should, 
indeed, in those who have never suckled, receive early attention, even be- 
fore the birth of the infant. Tightness of dress around the breast, as in- 
deed upon every part of the body, should be avoided, and from time to 
time gentle traction should be made upon the nipple, if it is depressed. It 
may be drawn out by the fingers of the mother several times each day, or 
by a common breast-pump, or by suction with a tobacco-pipe, the edge of 
the bowl having been smoothed. Occasionally, in these cases of deficient 
nipple, the mother, fatigued and discouraged by her frequent ineffectual 
attempts to induce the infant to nurse, becomes feverish and excited, so 
that the quantity of her milk is sensibly diminished. The physician should 
assure her, as he usually can with confidence, that in a few days, as the 
baby becomes a little stronger, there will be no difficulty in its nursing. 
Some women are unremitting in their endeavors to procure nursing. This 
should be forbidden, since the lack of sleep, and the nervousness which 
such constant attention produces, tend to defeat the object which they have 
in view, by diminishing the secretion of milk. The application of the in- 
fant to the breast once in an hour and a half to two hours is quite suffi- 
cient. In some cases, when practicable, the aid of another woman, whose 
infant is a little older, is invaluable. The exchange of infants for a few 
times may remedy the difficulty. 

Occasionally lactation is rendered difficult and painful by too long de- 
lay before applying the infant to the breast. When the mother has rested 
a few hours after her confinement, from three to six in ordinary cases, lac- 
tation may commence. There is, at first, but very little milk, often only 
a few drops, but the secretion is promoted by nursing, so that the requisite 
amount is sooner obtained than when the infant is kept from the breast 
till the second or third day. If, as some physicians advise, suckling is 
deferred till the breasts are full and tender, and if, as is often the case 
with primiparas, the nipples are also tender, many mothers lack the forti- 
tude required to allow their infants to obtain a sufficient amount of milk. 
Excoriated and fissured nipples constitute a serious impediment to lacta- 
tion. They are very sensitive on pressure, and are long in Iiealing. They 
are fully described in works which relate to female diseases, and their 
treatment pointed out. Occasionally fissured nipples do harm to tlie in- 
fant by the blood which escapes and is swallowed with the milk. A case 
is related in wliidi positive iiidini'stion was caused in this way, the infant 
vomiting, after each nursing, milk mixed with blood. The local hin- 
drances to lactation described above can, in most instances, be relieved in 
the course of a few weeks. 



30 LACTATION. 

There is, occasionally, a coustitutional state of the mother which necessi- 
tates either the employment of a hired wet-nurse or weaning. This is the 
case when there is a strong tendency to tuberculosis. If the complexion is 
pallid, and the system at all emaciated, and suckling is attended by more 
or less exhaustion, and if with fair trial of wine and tonics there is no im- 
provement, the physician is justified in forbidding farther attempts at wet- 
nursing. If there is, under such circumstances, an hereditary tendency to 
tuberculosis, it 'is his duty to interdict it positively. The opinion of the 
physician, in such a matter, should be formed after mature deliberation. 
There are many women who, suffering temporarily from depression, and 
discouraged, are ready at once to abandon their infants to the care of 
others, with the least encouragement on the part of the physician to do so, 
but who, by attention to their own health, and especially by taking more 
sleep, soon recover from their depression and become good wet-nurses. On 
the other hand, night-sweats, a cough, and progressive decline in health, 
show the need of immediate suspension of wet-nursing. 

Sometimes women, prior to pregnancy, present indubitable evidence of 
tuberculosis, but by the improved general health which attends pregnancy, 
the disease is temporarily arrested. Such women should never suckle their 
infants. If they do, they soon lose all that was gained, and the disease ad- 
vances rapidly. These objections to wet-nursing in such a state of health 
apply to the mother. There are also objections as regards the infant. The 
milk of those in decidedly infirm health, is deficient in nutritive principles. 
Their infants, therefore, are ill-nourished, and, if they have inherited a pre- 
disposition to tuberculosis, there is great danger that this disease will be 
developed in them ; whei-eas with healthy wet-nursing, even a strong pre- 
disposition may remain latent. M. Doune relates the following instructive 
cases, which show the danger which sometimes attends suckling, and the 
imperative necessity which may arise of discontinuing it. "A very light- 
coraplexioned young mother, in very good health, and of a good constitu- 
tion, though somewhat delicate, was nursing for the third time, and as re- 
garded the child successfully. All at once this young woman experienced 
a feeling of exhaustion. Her skin became constantly hot; there were 
cough, oppression, night-sweats ; her strength visibly declined, and in less 
than a fortnight she presented the ordinary symptoms of consumption. 
The nursing was immediately abandoned, and from the moment the secre- 
tion of milk had ceased, all the troubles disappeared." " A woman of forty 
years of age . . . having lost, one after another, several children, all 
of whom she had put out to nurse, determined to nurse the last one her- 
self. . . . This woman, being vigorous and well-built, was eager for the 
work, and, filled with devotion and spirit, she gave herself up to the 
nursing of her child with a sort of fury. At nine months, she still nursed 
him from fifteen to twenty times a day. Having become extremely emaci- 



HINDRANCES TO LACTATION. 31 

ated, she fell all at once id to a state of weakness, from which nothing could 
raise her, and two days after the poor woman died of exhaustion." 

A very similar case recently occurred in my practice. A young and 
healthy woman from the country, suckling her second infant, on coming 
to the city, lived in a dark and very imperfectly ventilated room, on the 
first floor, and in the rear of a crowded tenement-house. She soon lost her 
appetite, but continued suckling for three months, when she became so 
anaemic and feeble that she was compelled to seek medical advice. She 
died W'ithout local disease, notwithstanding the most nutritious diet and 
the free use of stimulants and tonics. 

Constitutional syphilis in the mother does not contraindicate lactation. 
It is probable that the infant also has it. The mother should take anti- 
syphilitic remedies, which will eradicate the disease in herself, and also, if 
it be present, in the infant. Febrile affections, also, do not in general con- 
traindicate lactation. They may, however, for a time, diminish the quantity 
of milk, or impair its quality. If, however, the mother is in a critical state, 
or much reduced, whatever the disease, suckling should cease. Whether 
or not the infant should be taken from the breast, if the mother is suffering 
from one of the essential fevers, depends on the severity of the malady, and 
the degree of her exhaustion. Twice I have known newly born infants 
nurse their mothers through attacks of scarlet fever, without contracting 
it, but suffering immediately afterwards from severe and protracted eczema. 
In the country, where artificially fed infants as a rule do well, it might be 
best to wean if the mother is affected with such a disease, but in the city 
eczema is less dangerous than the diarrhoeal affections which early wean- 
ing is apt to entail. In most cases of typhus or typhoid, weaning or pro- 
curing a wet-nurse is necessary, on account of the depression of the vital 
powers which this disease produces. 

Inflammatory affections, unless of a dangerous character, do not ordinarily 
interfere with lactation, except that the quantity of milk may be somewhat 
diminished. In severe inflammation, it may be so necessary to husband the 
strength, or to keep the patient perfectly quiet, that suckling her infant 
would be injudicious. It should then be transferred to a wet-nurse or 
weaned . Inflammation of the breast often presents an impediment to lacta- 
tion. It is a common and painful affection, suspending, or greatly dimin- 
ishing the secretion of milk in the affected gland. Nursing should cease 
as soon as there are evident signs of inflammation, unless it is limited to a 
small part of the gland. General heat of the breast, tenderness and in- 
duration extending over a considerable part of it, are signs which indicate 
the immediate removal of the infant from it. Lactation must be restricted 
to tlie unaflected side. It is often the case that the volume of the inflamed 
gland is considerably increased from the afflux of blood to it, and from 
the interstitial exudation, while it contains littler or no milk, and attempts 
at lactation, under such circumstances, are injurious to the mother as well 



32 LACTATION. 

as infant. The cause of the swelling should be explained to the mother, 
who commonly attributes it to the accumulation of milk, and worries her- 
self and the infant, in attempting to make it nurse. As the inflammation 
abates, by resolution, or more commonly by suppuration, and the normal 
secretion returns, the first milk, which is apt to be thick and stringy, should 
be rejected, after which the infant may nurse as usual. Occasionally, the 
abscess, which has formed in the breast, connects with a lactiferous tube, 
so that pus may, on suction, escape from the nipple. If this occur, of 
course, lactation should be interdicted, until pure milk is obtained. Pus 
in the milk can sometimes be detected by the naked eye. It presents a 
yellowish or greenish color, occurring in streaks, when not intimately 
mixed with the milk. When it is intimately mixed, and in small quan- 
tity, it cannot be detected by the naked eye, but the microscope reveals 
the pus-globules. M. Donne relates a case in which he discovered pus- 
globules by the microscope, although there were at first no other evidences 
of an abscess, and doubts were expressed in reference to the accuracy of 
his observation. Finally, an abscess pointed and discharged. 

Sometimes, when the inflammation abates, the secretion does not return, 
and, worse still, occasionally the inflammation has occurred so near the 
nipple that the lactiferous tubes are permanently closed by it, so that, 
though milk forms in the breast, there is no escape for it. Thenceforth 
lactation must be entirely from one breast. 

If erysipelas occur in the mother the infant should be immediately 
taken from her breast and from her arms. If this disease should not be 
communicated to the infant through the milk, or through fissures in the 
nipple, of which there is danger, still the milk is apt to undergo such 
change in consequence of the erysipelas as to endanger the health of the 
child. Thus, one of the wet-nurses in the New York Infant Asylum 
sickened with severe facial erysipelas on the 24th of April, 1875, eight 
days after the death of her baby. She was wet-nursing a foundling, aged 
seven weeks, at the time of the commencement of the erysipelas, and as 
it was very important that her milk should be preserved for the coming 
hot months, it was deemed best to allow the suckling to continue, the 
infant being placed in a crib at a little distance as soon as it dropped the 
nipple. On the 27th diarrhcea commenced in the baby. April 28th its 
morning tempei-ature was 101°, and that of the evening 103°, the diar- 
rhoea continuing. It was now removed entirely from the breast, and was 
given artificial food. On the 29th there was a decided general icteric hue 
of the infant's surface, which continued till its death on May 1st. The 
stools numbered about eight daily till April 30th, when they ceased. The 
record which I preserved does not state whether there was vomiting, but 
it had probably been slight on account of the speedy prostration. Death 
occurred from exhaustion. At the autopsy, from half an ounce to one 
ounce of pus was found in the peritoneal cavity, newly formed fibrin was 



FACTS AND RULES IN REFERENCE TO LACTATION. 33 

observed upon the spleen and liver, and the peritoneum generally had 
lost much of its lustre ; a careful microscopic examination of the liver 
and its ducts, made by Dr. Heitzmann, revealed no anatomical change 
which would explain the icteric hue, and it seemed probable that this was 
due to the altered state of the blood. The mucous membrane of the 
intestines exhibited vascular streaks, and its follicles were distinct. The 
lesions therefore indicated intestinal catarrh. Nothing unusual was ob- 
served in the heart and lungs. 

Facts and Rules in reference to Lactation. 

The new-born infant should nurse every hour or every second hour 
during the day. At night, if the mother is delicate and her milk not 
abundant, it may be fed once or twice with a little cow's milk. It is 
better to select for this purpose the upper third of the milk, after it has 
stood two or three hours, and use it diluted with twice the quantity of 
water. If the mother is robust she should not feed the infant, but allow 
it to nurse once or twice during the night. No nursling, in ordinary 
health, really requires the breast more than once during the hours which 
the mother needs for rest ; and by a little perseverance on her part its 
habits may be so established that it is satisfied if it receives the breast no 
oftener. Many young mothers commence the duty of suckling with too 
much ardor. Exerting themselves to the utmost for the good of their 
offspring, they are awake, night after night, giving their breast at every 
cry, till they find that their strength is failing, and with it also their milk. 
Their self-devotion necessitates early weaning, whereas, had they exercised 
more regard for their own health, and learned to hear with composure the 
cries, which often do not indicate any bodily want or distress, they might 
continue to suckle their infants during the usual period. 

The milk secreted during gestation, and immediately after the birth of 
the infant, differs iu its gross appearance, as well as chemical and micro- 



I 





Milk globules. 




scopical characters, from that which is ordinarily secreted in a slate of 
health. It is termed colostrum. It has a turbid and yellowish upi)ear- 

3 



34 LACTATION. 

ance, and is somewhat viscid. It is decidedly alkaline, and unc 
lactic acid fermentation more readily than common milk, and it also con- 
tains more solid matter. It has an excess of fat, of salts, and, according 
to Simon, also of sugar. It appears, from Simon's analysis, that the solid 
matter of colostrum is about seventeen per cent., while that of the ordi- 
nary breast-milk is about eleven per cent. 

Examined by the microscope, the colostrum is seen to contain oil -glob- 
ules and a viscid substance, which often assumes an ovoid or globular 
form, but which also exists in irregular masses of considerable size. This 
substance has been thought by some to be mucus, but it is dissolved by 
acetic acid and potash, and is tinged yellow by a watery solution of iodine. 
It is, therefore, to be regarded as albuminous. Imbedded in this sub- 
stance are oil-globules, which are for the most part of small size, while 
the free oil-globules of colostrum are larger than those occurring in 
healthy milk. This viscid substance, with the imprisoned oil-globules, 
constitutes what has been designated the " colostrum-corpuscles." Some 
have erroneously considered the " colostrum-corpuscles " to be compound 
granular cells. The compound granular cell, or corpuscle, is a cell which 
has undergone fatty degeneration. It is distended with oil-globules to 
perhaps twice or thrice its normal size. On the other hand, examination 
of the "colostrum-corpuscles" fails to detect a cell-wall, and the large 
and irregular size of some of these corpuscles negatives the idea that they 
are cells. The oil-globules contained in the viscid substance axe more 
readily acted on by ether than are the free oil-globules. 

The colostrum is replaced by milk of the normal character, in six to 
eight days; sometimes as early as the third or fourth day after delivery. 
In exceptional instances, the colostrum does not disappear for several weeks, 
and it may reappear at any time during lactation, as a consequence of de- 
rangement of the system, or from disease. It is assimilated w'ith difficulty 
by the digestive organs of the infant, producing usually a laxative effect. 
It, therefore, aids in the removal of the meconium, and being a normal 
secretion in the first week of lactation, it is to be regarded as beneficial. 
Continuing longer than the first week, its effect is deleterious. It produces 
evident derangement of the digestive organs, and the infant that habitu- 
ally nurses it never thrives. It has diarrhoea or vomiting, becomes more 
or less emaciated, and suffers from colicky pains. Sometimes an extreme 
degree of exhaustion is reached before the cause is suspected, for, if the 
milk is pretty abundant, the admixture of colostrum with it cannot be de- 
tected by the naked eye. The microscope alone reveals it. The follow- 
ing is an interesting example of this fact. In 1868 an infant six weeks 
old was brought to me, with the following history. The mother had for 
years been troubled more or less with dyspeptic symptoms, but had other- 
wise been in good health. The infant at birth was fleshy and strong, but 
after the first week it had never thriven like other infants. It nursed 



FACTS AND RULES IN REFERENCE TO LACTATION. 35- 

regularlj, and the quantity of milk was apparently sufficient, but it 
vomited as soon as it ceased nursing; it was much emaciated, and the 
bowels were habitually constipated. The digestive organs of the infant 
had been in this unhealthv state, with little variation, from the first week, 
and it was very evident, from the emaciation and exhaustion, that it must 
soon perish, unless some change wei-e effected. The milk of the mother 
presented the usual appearance to the naked eye, but under the micro- 
scope colostrum-corpuscles were observed. A wet-nurse was immediately 
obtained, and from that moment the gastro-intestinal symptoms disap- 
peared, with a rapid recovery. This case shows at once the evil effects of 
the colostrum, and the need of a microscopic examination of the milk 
whenever the nursling suffers from lactation. 

Human Milk. 

The specific gravity of human milk is about 1032. It has been care- 
fully analyzed by different chemists, with nearly the same result. The 
following table, prepared by MM. Vernois and Becquerel, gives the pro- 
portion of the various ingredients in 1000 parts: 

Water, 889 08 

Sucrar, . 43.64 

Caseuin and extractive, ...... 39.24 

Butter, '. 26 66 

Salts (ash), L38 

1000.00 

Milk being the. sole food of early infancy, contains all the nutritive 
principles which are required for the growth and repair of the different 
tissues. The caseum is an albuminous principle, the butter and sugar are 
combustible substances, and most of the salts which occur in the different 
tissues exist primarily in the milk. Phosphate of lime, phosphate of mag- 
nesia, phosphate of the peroxide of iron, chloride of potassium, chloride of 
sodium, and soda, known to exist in cow's milk, are believed to occur also 
in human milk. Epithelial cells are sometimes present, derived from the 
lining membrane of the lactiferous tubes. 



Modifications of the Milk in consequence of the Diet. 

Fresh milk should give an alkaline reaction, but in certain states of ill 
health, or after the u.se of certain articles of food, the reaction is acid. 
Mothers are well aware of the ill effects, as regards the infant, which fol- 
low their use of indigestible, or acescent food; and, if prudent, they avoid 
it. The milk, if the diet of the mother is improper, may become so 
strongly acid as to cause colicky pains and diarrhoea. The following ob- 



36 LACTATION. 

servations in reference to cow's milk are instructive. We may infer from 
them that the regimen of the mother exerts a decided influence on the 
alkalinity of her milk. According to Routh (Infant Feedinr/, page 285), 
stall-fed cows almost always give acid milk. Dr. Mayer, of Berlin, ex- 
amined the milk from a considerable number of cows, with the following 
result: 

(«.) Of cows fed with brewers' lees, red potatoes, rye bran, and wild 
hay, in five instances the milk was slightly sour; in one very much so. 

(6.) Of forty cows fed with potato mash, barley husk, and clover and 
barley straw, in ten, which were examined, the milk was sour; in three 
very sour. 

(c.) From among fifty cows fed on potato husks, barley husks, and wild 
hay, five were examined, and in all the fresh milk was sour. 

(d.) From forty-two cows fed on potato mash, husks, wild hay, and rye 
straw, out of twelve selected for examination, the fresh milk of all was 
sour. 

(e.) From six cows fed by a chief gardener on coarse beet-root, red po- 
tato, bran mash, and hay, the fresh milk was slightly sour. 

(/.) From five cows fed by a cow-feeder on lukewarm bran mash and 
hay, in four the fresh milk was quite neutral, in one it was decidedly alka- 
line. (Roidh.) 

The above observations of Dr. Mayer were made in the winter season, 
and it is possible tliat the acidity may have been partly due to the confine- 
ment of the cows in stalls. But that it was mainly due to the food is evi- 
dent from the fact that it was greater with some kinds of food than others. 
Cows' milk is not so alkaline as human milk, and is therefore more readily 
rendered acid. Still, what Dr. Mayer observed in reference to the cow 
exemplified a fact of general applicability, namely, that certain kinds of 
food may affect the alkalinity of the milk, whether human milk or that of 
animals. 

The relative proportion of the different ingredients of the milk varies 
according to the diet. If the diet is poor, the amount of water increases, 
and that of butter and caseum diminishes. Lehmann says (Phys. Chem- 
istry, vol. ii, p. 65) : " From experiments made on bitches, it would appear 
that a vegetable diet renders the milk richer in butter and sugar; while 
the solid constituents are augmented when a sufficient quantity of mixed 
food is given. Peligot found the milk of an ass most rich in casein when 
the animal had been fed on beet-root ; whilst it was richest in butter when 
the food had consisted of oats and lucerne. Fat food increases the quan- 
tity of the butter. Boussingault found the milk of a cow richer in casein 
when the animal had been fed on potatoes than when other food was taken. 
Reiset found that the milk of cows which were at grass was much richer 
in fat than when the animals had stood all night in their stall without 
food ; but Playfair found, on the contrary, that the quantity of butter in 



MODIFICATION OF MILK BY NERVOUS IMPRESSIONS. 37 

the milk increased during the night as much as during their stall-feeding, 
but that the quantity of butter in the milk was considerably diminished 
by the motion of the animals in the fields."^ Simon made the following 
analyses of the milk of a poor woman. She was suddenly, during the 
period of lactation, deprived of the means of support, so that her food was 
insufficient in quantity, and of poor quality. The amount of her milk was 
not diminished by privation, but the solid constituents were reduced to 86 
parts in 1000. After this, for a time, her diet was nutritious and abun- 
dant, the quantity of milk was increased, and the solid constituents 
amounted to 119 parts in 1000. Her diet was again reduced, with a re- 
duction of the solid elenrients to 98 in 1000, and, at a later period, the diet 
was again nutritious, with an increase of the solid elements to 126. The 
chief variation observed in the milk of this woman was in the amount of 
butter. 



Modification of Milk from its retention in the Breast. 

M. Peligot has clearly demonstrated, that the longer milk is retained in 
the breast the more watery it becomes. This is explained on the supposi- 
tion that the solid portion is first absorbed. Therefore, the milk is richer 
the more frequently it is removed from the breast. A similar fact, which 
has the same explanation, has long been known, namely, that the first 
milk taken from the breast is thinnest, while that which flows last is 
richest. That first removed has remained longest in the gland, while that 
which comes last is but recently secreted. 

A knowledge of this fact is of considerable practical importance. The 
milk, as M. Donne has shown, may be too rich, so as to cause indigestion, 
with more or less enteralgia, in the infant. Some nurslings, if the milk is 
too rich and abundant, reject a part of it by vomiting, but others do not, 
and suffer the consequence in derangement of the digestive organs. For 
such cases the remedy is, to give the breast less frequently, by which a less 
amount of milk is taken, and milk of a poorer quality. On the other 
hand, if there is poverty of the milk, and the infant is insuflliciently nour- 
ished, the milk is more nutritious if the nursing be at short intervals. 



Modification of Milk by Age and by Mental Impressions. 

The composition of the milk varies, also, according to the age of the 
infant. Simon analyzed the milk of a woman at intervals for the period 
of about six months. In this case the amount of casein at first was small, 
but the quantity increased during the two niontl)s succeeding delivery, after 
which it was nearly stationary. A similar increase was ob.served in refer- 

1 Animal Chcm., Sydenham Soc.'s Trans., vol ii, p. 55. 



38 LACTATION. 

ence to the saline substances. The sugar, on the other hand, diminished 
in quantity as the infant gre\y older, its maximum amount being in the 
first and second months. The quantity of butter in the milk varies from 
day to day more than the other elements. 

Many observations have been published which show that the composi- 
tion of the milk may be materially changed by mental impressions. The 
infant has died suddenly in the act of nursing, after the mother had been 
violently excited. Such a case is related by Tourtnal. The infant ceased 
nursing, gasped, and died in the mother's lap. In other cases convulsions 
have occurred. MM. Becquerel and Veruois made the chemical analysis 
of the milk of a woman in a state of nervous excitement, and found that 
the solid constituents were diminished to 91 parts in 1000, the most marked 
diminution being in the butter, which was only about 5 parts. In a case 
related by Parmentier and Deyeux the milk became watery and viscid, 
and remained sp till the nervous attacks, from which the patient suflfered, 
had ceased. Dairymen are well aware how ill-treatment and the separa- 
tion of the calf from the cow diminishes the milk which she yields. A 
new milkman seldom obtains as much milk as one with whom the cow is 
familiar. Bouehut, alluding to the influence of the moral affections on the 
secretion of milk, makes the following remark, the truth of which most 
mothers will acknowledge: "It is also a fact, that the sight of the nurs- 
ling, the idea of seeing it at the breast, and the joy which certain mothers 
thence experience, exercise a moral influence over the secretion of the milk 
entirely independent of their will. They feel the draught of milk as soon 
as they behold their child, or think of it too deeply; and in a woman who 
saw her child fall to the ground, the flow of milk ceased, and did not 
reappear until the child, having quite recovered, attempted to take the 
breast." 



Modification of Milk by the Catamenial Function and Pregnancy. 

The catemeuia reappear in most women before the close of lactation, 
often by the fifth or sixth month after delivery. If this function is re-es- 
tablLshed in the normal manner, that is, without any derangement of the 
system, without pain or undue profuseness, no unfavorable result ordi- 
narily occurs with the infant. On the other hand, if the mother suffer any 
disturbance of the system, or if the menses are profuse, the lacteal secre- 
tion may be so changed that the infant is injuriously affected by it. The 
symptoms produced are those of indigestion, such as abdominal pains, more 
or less vomiting, and diarrhoea. This result is, however, in my experi- 
ence, quite exceptional. In rare instances, more dangerous symptoms 
occur in the infant. A case has been reported to me in which, at each 
catamenial period, the nursling was seized with convulsions. 

MM. Becquerel and Vernois have investigated the character of the milk 



I 



MODIFICATION OF MILK, ETC. 39 

during the catamenia in three cases. Their examinations showed a mod- 
erate increase in the solid constituents. The butter and caseum were in- 
creased, while the sugar was diminished. The variation from normal milk 
was not, however, such as would be likely to cause any serious indisposi- 
tion. If the menses reappear with regularity, when the infant has attained 
the age of ten or twelve months, they should be considered as designed to 
supersede the secretion of milk, which, indeed, usually begins to diminish. 
Weaning is then proper. If the menses return early in the period of lac- 
tation, and give rise to symptoms in the infant in consequence of the 
altered quality of the milk, it is advisable to allow but little nursing dur- 
ing the catamenia, and to employ artificial feeding in place till the flow of 
blood ceases. 

The change produced in the milk by pregnancy is, in general, more in- 
jurious to the nursling than that caused by the reappearance of the menses. 
The milk of the pregnant woman is apt to contain more or less of that 
viscid substance which characterizes colostrum. Still, the milk of preg- 
nancy does not, ordinarily, derange the digestive function as much as col- 
ostrum, in the first weeks of lactation, for pregnancy rarely occurs till after 
the infant is five or six months old, when the organs of digestion are less 
readily disturbed. The injurious effect of pregnancy on the infant is 
shown by vomiting or diarrhoea, by restlessness and occasional abdominal 
pains, in fine, by symptoms of indigestion. In many cases, however, these 
symptoms do not occur, and the infant, though nursing regularly, con- 
tinues to thrive. No doubt, as a rule, the infant should be weaned when 
there are clear evidences of pregnancy, but under certain circumstances 
weauiug is injudicious. I have, on difiTerent occasions, been called to in- 
fants, in raidsummei', dangerously sick with diarrhoeal attacks induced by 
this cause. These infants were, perhaps, doing well, or sufiTering but little 
from indigestion, when the mothers suspecting themselves pregnant, at 
once withdrew them from the breast, and cholera infantum or a kindred 
disease was the result. No infant in the city should be weaned in the hot 
months. It is much safer, though there are indubitable signs of preg- 
nancy, that it continue nursing till the cold weather. The better method 
is, however, under such circumstances, to employ a wet-nurse, or to remove 
the infant to the country, and wean it there. In cold weather, it is usu- 
ally safe to wean an infant in the city alter it has reached the age of five 
or six months. 

The milk frequently contains other ingredients in addition to those 
which have been mentioned. Thus a large number of medicinal sub- 
stances, taken by the mother, may enter the milk, so as to produce their 
characteristic effect on the infant. It is a well-known fact, tliat the pecu- 
liar flavor of certain vegetables, taken as food, may be noticed in the milk. 
It is admitted, also, that the specific virus of the contagious diseases, at 



40 LACTATION. 

least certain of tliem, may enter the milk, so as to give rise to the same 
diseases in the infant. 

Quantity of Breast Milk requiied by the Infant. 

In a paper published by Dr. W. H. Gumming, in the American Journal 
of Medical Science, July, 1858, it is estimated that the amount of milk 
secreted per day by a healthy woman is one and a half to two quarts, and 
double the quantity if two infants are suckled. Routh {^Infant Feeding, page 
87) believes that this is a somewhat exaggerated statement. He estimates 
the amount at a quart to a quart and a half daily. " A three months 
child," says he, "generally thrives very well, on four, or, at the most, five 
meals a day, the quantity taken each time amounting to a half pint. This 
would fix the quantity at two pounds to two and a half, i. e., thirty-two to 
forty fluid ounces. ... A younger child, one to two months, may need to 
take his meals more frequently ; it may be every two hours, except when 
asleep ; but then the quantity consumed does not exceed, as a rule, as I 
have often assured myself, two wineglasses or three ounces every meal. 
This would raise the quantity taken in twenty-four hours to thirty-six 
ounces, a quart and a quarter. A child above three months may take 
about forty-eight ounces daily." 

Dr. Gumming, in consequence of his high estimate of the amount of 
milk which an infant requires, naturally concludes that few mothers can 
long endure the excessive drain upon their systems ; and, therefore, in 
oi-der to prevent their exhaustion and to satisfy the appetite of their in- 
fants, it is necessary, at an early period, to aid by artificial feeding. This 
opinion may do harm, since artificial feeding of the young infant, espe- 
cially in the cities, is apt to give rise to indigestion, followed by vomiting 
and diarrhoea. The mother in good health, and furnishing an average 
quantity of milk, is competent to give all the nutriment which the infant 
requires until it has reached the age of four months, and most are till the 
age of six months. Drs. Merei and Whitehead examined 952 mothers in 
the Ghildreu's Hospital at Manchester, in reference to their physical con- 
dition. Of these 629, or 66 per cent., were in a healthy and robust state. 
Of this number, namely 629, 420 furnished sufficient milk till six months 
after delivery, and some till two years. 

Differences in Suckling Women as regards Quantity and Quality of Milk. 

There is, however, a great difference, in different women, as regards the 
quantity and quality of their milk, and even the mode in which it is 
secreted. The best wet-nurses are usually robust without being corpulent. 
Their appetite is good, and their breasts are distended from the number 
and large size of the bloodvessels and milk-ducts. There is but a mode- 
rate amount of fat around the gland, and tortuous veins are observed 



SCANTINESS OF MILK. 41 

passing over it. Such nurses do not experience a feeling of exhaustion 
and do not suffer from lactation. 

The nutriment which they consume is equally expended in their own 
sustenance and the supply of milk. There are other good wet-nurses who 
have the physical condition which I have described, but whose breasts are 
small. Still, the infant continues to nurse till it is satisfied, and it thrives. 
The milk is of good quality, and it appears to be secreted, mainly, during 
the time of suckling. Other mothers evidently decline in health during 
the time of lactation. They furnish milk of good quality and in abun- 
dance, and their infants thrive, but it is at their own expense. They them- 
selves say, and with truth, that what they eat goes to milk. They become 
thinner and paler, are perhaps troubled with palpitation, and are easily 
exhausted. They often find it necessary to wean before the end of the 
usual period of lactation. There is another class whose health is habitu- 
ally poor, but who furnish the usual quantity of milk without the exhaus- 
tion experienced by the class which I have just described. The milk of 
these women is of poor quality. It is abundant, but watery. Their infants 
are pallid, having soft and flabby fibre. All these kinds of wet-nurses 
are met in practice. 

Occasionally, a considerable part of the milk is lost by oozing from the 
breast. This sometimes occurs in robust women, but it is more frequently 
associated with weakness. It is then due to a relaxed state of the orifices 
of the milk-ducts. Galactorrhoea, as the excessive secretion and flow of 
milk is designated, is said to be often associated with a menorrhagic 
diathesis; that is, women whose menses have been profuse are apt to have 
too abundant a flow of milk corresponding with the menorrhagia. It is said 
that galactorrhoea is also apt to occur in those who are subject to discharges 
from parts which sustain no immediate relation to the breast, as in cases of 
hsemorrhoidal flux, diabetes insipidus, etc. Excitement, or irritation of the 
uterus or ovaries, may serve as an exciting cause of galactorrhoea in those 
predisposed to it, and excessive suckling may have the same effect. 

Scantiness of Milk; its Causes and Treatment. 

Though the amount of breast-milk which the infant requires is less than 
was estimated by Gumming, still insufficiency of this secretion is not un- 
common, especially in the cities. According to the statistics of Drs. Merei 
and Whitehead, among healthy mothers there is insufficiency in 16.5 per 
cent., while among mothers in feeble health the percentage is 46.6. In 
treating of this subject in the following pages, reference is not had to those 
cases in which there is temporary diminution of milk from acute disease 
or other pei'turbating causes, but to those cases in which there is habitual 
scantiness. 

One cause of scanty secretion of milk is a life of privation or of daily 



42 LACTATION. 

work, which necessitates separation from the infant. Insufficient food may- 
render the milk more watery, as has already been stated, or it may cause 
diminution in its quantity. The mother thus situated is pallid. She is 
subject to palpitation and attacks of faiutness. Her condition, indeed, is 
that of ansemia. Working women have scantiness of milk, not only in 
consequence of hardships, but also because they are usually separated for 
hours from their infants. Age is also a cause of scantiness of milk. 
Mothers at the age of forty years ordinarily furnish less milk than be- 
tween twenty and thirty. And those who have not borne children till 
late in life, and whose mammary glands have therefore long been inactive, 
have less milk than those who commence bearing children at the usual 
period. 

Routh speaks of hypersemia as a cause of defective lactation. " This 
is a variety," says he, "which I have chiefly observed among hired 
wet-nurses, selected from the poorer classes, and admitted into wealthier 
families. . . . When feeding at the expense of a master or mistress, the 
amount they devour often surpasses all moderate imagination. They, in 
fact, gormandize. If in such instances a wet-nurse is given all she asks for, 
she will be found often to eat quite as much as any two men with large 
appetites; and, as a result, she becomes gross, turgid, often covered with 
blotches or pimples, and generally too plethoric to fulfil the duties of her 
position. The plethora, as first induced, is of the sthenic variety, but it 
soon assumes an asthenic character, and, as the immediate result, the 
breast no longer secretes its quantum of milk. There may be good milk 
secreted, but it is in small quantity, and this quantity diminishes daily. 
The breast may also enlarge, but it is from a deposition of fatty tissue in 
and about it, as in other parts of the body. The veins on the surface be- 
come less apparent, always a bad feature in a suckling breast, till finally 
the flow of milk ceases altogether." 

Atrophy of the breast from the employment of iodine, or from long dis- 
use, is also a cause of insufficiency of milk. 

It is so necessary for the health and develo])ment of the infant that the 
milk should be in proper quantity as well as quality, that it is proper in 
a work of this kind to consider the treatment of insufficient secretion, and, 
on the other hand, of excessive secretion and loss of milk, or galactorrhoea. 
And first of insufficient or scanty secretion. 

The most eflicient mode of increasing the lacteal secretion is that which 
is also natural, namely, suction from the nipple. There are many cases ou 
record in which this has produced the flow of milk in women who have 
never borne children, and even in men. Baudelocque mentions the case 
of a girl, eight years old, who suckled her brother for a month, and cases 
at the opposite extreme of life have been reported ; one of a woman of 
seventy years, who wet-nursed a grandchild twenty years after her last 
confinement. 



SCANTINESS OF MILK. 43 

Travellers among barbarous nations or tribes have often observed these 
cases of unnatural lactation. Humboldt saw a man, thirty-two years old, 
who gave the breast to his child for five months, and Captain Franklin, in 
the Arctic regions, met a similar case. Dr. Livingstone, in his African 
travels, says that he has examined several cases in which a grandchild has 
been suckled by a grandmother, and equally remarkable instances of lac- 
tation occur among the negroes of the Southern and Middle States. Pro- 
fessor Hall presented to his class in Baltimore a male negro fifty-five years 
old who wet-nursed all the children of his mistress. In these cases of ab- 
normal lactation, so far as we have accurate records of them, it is ascer- 
tained that the breasts were torpid, and even sometimes, as in old people, 
atrophied till the nursing commenced. Titillation, or pressing of the nip- 
ple, caused an afflux of blood to the gland, and developed its functional 
activity, so that milk was produced for the sustenance of the nursling. 
Therefore, in ca.se of scanty secretion of milk, the mother may increase the 
quantity by applying the infant often to the breast. If, dissatisfied with 
the small amount of nutriment which it receives, it refuses to make the 
necessary suction, any other mode of gentle traction or pressure may be 
employed in addition. The occasional employment of another infant, or 
a pup, milking the breast with the thumb and fingers, or the gentle suc- 
tion of a breast-pump, aids in stimulating the secretion. Forcible rubbing 
or traction of the breast defeats the purpose for which it is employed. It 
produces too much irritation and tenderness. The best mode of stimula- 
tion is by nursing, as it is the natural mode, and the moral effect of the 
infant at the breast aids in promoting the secretion. 

Another mode of increasing the functional activity of the mamraaiy 
glands is by the electrical current. The fact is established by physiologi- 
cal experiments, that glandular organs can be made to secrete more ac- 
tively by the stimulus of electricity, and, accordingly, this agent has been 
successfully employed to promote the secretion of milk. In Routh's In- 
fant Feeding .several cases are related which show the beneficial effects of 
this agent (page 149 et seq.). Among them are six reported by Dr. Skin- 
ner, of Liverpool. In all these, one or two applications of the electrical 
current sufficed to restore the secretion. The following is Dr. Skinner's 
mode of employing this treatment: 

" 1. Direct. — Both poles must terminate in cylinders, with sponges well 
moistened in tepid water. The positive pole is pressed deep into the axilla, 
while the negative is lightly applied to the nipple and the areola; the cur- 
rent being no stronger than is agreeable to the patient's feelings. The 
poles are kept in this position for about two minutes. Both poles are then 
to be inserted into the axilla, and gradually brought together, the nega- 
tive to the sternal, and the positive to the opposite of the organ. This 
latter step may occupy one or two minutes more. 

" 2. Intramammary. — The poles are to be, as it were, imbedded in the 



44 LACTATION. 

mamma, and moved about, raising and depressing both poles at once in 
and around the organ for the space of another two minutes. The same is 
to be done to both breasts daily, until the secretion is properly established. 
Hitherto one or two sittings have always sufficed in my hands." {Com- 
munication of Dr. Skinner to Dr. Bouth.) 

In all cases of scanty secretion of milk, the regimen of the mother is a 
matter of importance. Personal and domiciliary cleanliness is essential 
for successful wet-nursing. A certain amount of exercise in the open air 
is conducive to the health of the mother, and to the secretion of abundant 
and healthy milk. A case is related to show the effect of fresh air and 
outdoor exercise on the lacteal secretion. A lady of cleanly habits, living 
in London, had a very scanty supply of milk. She removed to the pure 
air of the seashore, and immediately the quantity became abundant, and 
continued so for months. Such cases are not unfrequent. A mode of life 
that contributes to the general health of the mother will not fail to aug- 
ment the quantity of her milk, if it is scanty, and to improve its quality. 

Much has been written in reference to the diet of women who suckle. 
It is a popular belief that certain articles of food promote the secretion of 
milk much more than other articles, though equally nutritious. No doubt, 
writers have erred in recommending exclusively this or that kind of food, 
as most likely to produce milk. The exact kind of food which is prefer- 
able, in a certain case, depends partly on the physique of the individual, 
and partly on the character of the food to which she has been accustomed. 
A mixed diet contributes most to the sustenance of the mother, and to an 
abundant secretion of milk. Animal substances which furnish a due sup- 
ply of nitrogenous aliment should be given with the farinaceous. Mothers 
pallid, and inclining to an aniemic condition, require a larger proportion 
of animal diet than those in good general health. On the other hand, 
plethoric women, such as Routh describes, who with excellent appetites 
consume large quantities of food, and who become more and more full- 
blooded aud corpulent while the milk diminishes, require a more restricted 
animal diet, in connection with more exercise, especially in the open air. 

There are certain kinds of food which do appear to have a galactogogue 
effect with most wet-nurses. Oatmeal gruel is one of these. Wet-nurses 
often remark, after taking a bovvl of this, that they feel the flow of milk. 
Cow's milk with some has a similar effect. Porter or ale, taken once or 
twice a day, also promotes the secretion of milk, especially in those who 
have poor appetite, and whose systems are somewhat reduced. 

A great variety of medicines have been used for their supposed galac- 
togogue effect. Medicines which improve the general health are, no 
doubt, sometimes useful for this purpose, such as the vegetable and ferru- 
ginous tonics and, perhaps, cod-liver oil. But there are other medicines 
which it is claimed have a specific effect on the mammary gland, pro- 
moting its secretion. Lettuce, winter-green, fennel, the broom tops (citi- 



SCANTINESS OF MILK. 45 

sus scoparius), marsh-mallow, castor oil plant, aud many other plants have 
been used for this purpose. There can be no doubt that the aromatic 
stimulants, as fennel, anise, and caraway seeds, given in soups, sometimes 
stimulate the lacteal secretion. Another medicine which of late has been 
recommended to the profession, as a galactogogue, is castor oil and the 
plant from which it is derived. 

The galactogogue effect of the leaves of the castor oil plant has been 
long known to the Spaniards in South America. At least as long ago as 
the commencement of the last century the ricinus communis was applied 
by them externally to the breast to promote the secretion of milk. It is 
now about twenty years since this use of the plant was brought promi- 
nently to the notice of the profession in this country aud in Europe. In 
the London Journal of Medicine, 1857, Dr. Tyler Smith I'elates the results 
of his experiments with the castor oil plant. He applied the bruised 
leaves over the breasts, and witnessed, as he thinks, an evident galacto- 
gogue effect. Dr. Eouth has also made pretty extensive use of the plant, 
both externally and internally. He was led, he says, to employ it inter- 
nally, from noticing in suckling women an increase of milk after taking 
a dose of castor oil. He prescribed a decoction of the leaves and stalks, 
and says: "I have not been disappointed. The flow has been remarkably 
increased. Four objections against its use, however, should be mentioned." 
These are, first, a peculiar sensation in the eyes, with dimness of sight, an 
effect which he has observed only in weak women ; secondly, the necessity 
of increasing the dose as the patient becomes accustomed to it ; thirdly, 
scarcity of the plant ; fourthly, an occasional diuretic, sometimes without 
galactogogue effect, and sometimes with it. The cases in which diuresis 
occurred were in the practice of other physicians, and Dr. Routh conjec- 
tures that this effect was produced by not keeping the breast warm during 
the time that the decoction was being employed. The breasts should, at 
the time of its use, be covered with a fomentation of leaves, or an extract 
of the leaves should be rubbed over the breasts in the same way iu which 
extract of belladonna is used, and over this a warm poultice applied of 
the ordinary material. Dr. Routh remarks: "When the castor oil leaves 
are given as an infusion to women who are not suckling, I have observed 
two effects, both of which seem to denote its specific action. First, it 
produces internal pain in the breasts, which lasts for three or four days. 
Then, secondly, a copious leucorrhoeal discharge takes place, after which 
the effect on the breasts entirely disappears." 

Dr. Gilfillan, of Brooklyn, has also employed the ricinus communis 
successfully as a galactogogue. He employed a poultice of the pulverized 
leaves, and gave internally the fluid extract of the leaves, a teaspoonful 
three times daily. The patient had been confined the year before with 
her first child, but had no milk for it, though her health was good, and 
measures were emjiloyed, as friction and fomentations, to stimulate the 



46 LACTATION. 

secretion. The riciuus was prescribed the fourth day after her confine- 
ment with the second child, when there were no signs of secretion, and 
the breasts were small. "About two hours after the poultice was applied, 
and the first dose taken, she experienced a strange sensation in the breasts, 
and this increased after each dose of the medicine. The poultice was not 
renewed, but the extract was continued for three days, after which lacta- 
tion was perfectly successful." So far observations have shown that the 
ricinus is the most eflScient galactogogue which we possess among medici- 
nal agents. 

In the treatment of galactorrhoea the object to be attained should be 
kept in view. There are medicines which cure this affection by diminish- 
ing the amount of milk. Belladonna, iodide of potassium, and colchicum 
are autigalactics. It is proper to use them in case of weaning or of death 
of the infant. They not only reduce the quantity of milk, but, contin- 
ued, may prevent its secretion. They are employed not to benefit the 
infant, but the mother. 

On the other hand, if it is our purpose to prevent the oozing of milk in 
order to save it lor the infant, or, if it is abundant and watery, to diminish 
somewhat its quantity and improve its quality, the treatment should be 
different. Iron, in cases of galactorrhoea, in which the condition of the 
system appears to indicate the need of it, will diminish the quantity of 
milk and render it richer. It is by many regarded as an antigalactic, and 
given long it might reduce too much the amount of the secretion, and even 
necessitate weaning. Its use should be discontinued if no more than the 
normal amount of milk is secreted. 

In most cases of true galactorrhoea the pathological state is that of weak- 
ness and relaxation of the tissues. The fault is not excessive secretion of 
milk so much as its non-retention, and the medicines which are the most 
useful to correct this state of the system and of the breasts are the vege- 
table tonics and astringents. If galactorrhoea occur in those who have an 
habitual discharge, and it appears to be due to the same cause which pro- 
duces that discharge, and there are no evidences of weakness, laxative 
medicines and other derivatives may be employed. But such cases are not 
common. Nux vomica has been recommended in galactorrhoea, in the 
belief that it diminishes the relaxation of the orifices of the lactiferous 
tubes. 

Local treatment in this affection is important. A cloth wrung out of 
cold water should be occasionally applied around the nipple, and removed 
as it becomes warm. Solutions of tannin or alum are likewise useful. 
Collodion applied around the nipple, by its contraction, diminishes the ori- 
fices of the ducts, and thus aids in the retention of the milk. 



SELECTION OP A WET-NURSE. 47 



CHAPTER V. 

SELECTION OF A WET-NURSE. 

In the cities cases are frequent in which mothers, with all possible care 
or endeavor, find themselves unable to suckle their infants. Their health 
is too poor, or the milk possesses the properties of colostrum, or it is no 
longer secreted, on account of nervous excitement, or exhaustion, or in- 
flammation of the breasts. The number of such cases in the city would 
surprise physicians who are familiar only with the healthy and robust 
mothers of the country. The infant thus deprived of the mother's milk 
should, if practicable, be furnished a wet-nurse. 

The selection of a wet nurse often devolves upon the physician, and it 
is a duty of great responsibility. It is better to select one between the 
ages of twenty and thirty years, and one who has suckled an infant pre- 
viously. A wet-nurse between the ages of twenty and thirty is usually 
moi'e active, cheerful, and conciliatory than one of a more advanced age, 
and her milk is more apt to be abundant and nutritious. Those who have 
previously suckled and had charge of infants are obviously more compe- 
tent to serve as wet-nurses than are primiparse. The milk of a wet-nurse, 
whose infant is under the age of six mouths, will ordinarily agree with a 
new-born infant. If above that age, it sometimes agrees, but often does 
not. 

The most difiicult and responsible task imposed on the physician in the 
selection of a nurse, is to ascertain the exact condition of her health, and 
the quantity and quality of her milk. Constitutional syphilis is common 
in the class of women who present themselves for wet-nursing; it is often 
latent, or its symptoms are easily concealed, and it is communicable by 
lactation. The virus may be received by the infant from fissures or ex- 
coriations of the nipple. The nursling tainted by syphilis may, on the 
other hand, communicate the disease to the nurse through the same source. 
It is not fully ascertained whether the syphilitic virus may be conveyed to 
the infant by the milk. But the cases which have accumulated in the 
records of medicine are numerous, in which infants born of healthy parents 
have been fully syphilized by lactation from diseased nurses (see article 
Syphilis). These infants have sometimes led a short and miserable exist- 
ence, and have occasionally increased the misery of the household by im- 
parting the disease to others. The duty is, therefore, imperative on the 
part of the physician to examine carefully the wet-nurse, in reference to 



48 SELECTION OF A WET-NURSE. 

any evidences of the syphilitic taint. Acquainted with tlie symptoms of 
syphilis, he may usually, by shrewd questioning aud by careful examina- 
tion of the present appearance and condition of the woman, ascertain with 
considerable certainty whether her system has ever been infected. Refer- 
ences should also be obtained and consulted, and, if practicable, the phy- 
sician who has attended her be communicated with. 

There are, also, among the women who present themselves for wet- 
nursing in the cities, many of a scrofulous habit, many who possess an 
hereditary tendency to tuberculosis, if indeed they do not already have 
the incipient disease. Such applicants should be rejected, on account of 
the poverty of their milk and the probability that they will not be able to 
endure the debiliating effect of lactation. 

The milk should be examined, in order to ascertain its richness and 
quantity, and whether it contains colostrum. If there is colostrum after 
the eighth day, it is probable that there is some fault in the health or di- 
gestion of the wet-nui'se, and that her milk may disagree with the infant. 
It is not necessary that the breast should be large, in order to furnish a 
sufficient quantity of milk, since, as has been already stated, in some the 
secretory function is active during the time of each nursing, so that, al- 
though the breasts are of moderate size, a sufficient amount of milk is 
furnished. The nipples should be well formed and prominent, and prefer- 
ence is to be given to those wet-nurses in whom bloodvessels are seen 
ramifying over the breasts. 

By examination of the milk, its degree of richness can be readily ascer- 
tained. A quantity of it should be placed in a test-tube, and the cream, 
which rises to the top, indicates, approximatively, the character of the milk. 
Good milk furnishes three per cent, of cream, and the caseum and sugar 
usually correspond in quantity with the cream. An instrument has been 
invented, called the lactometer, by which the exact amount of the cream 
can be ascertained. It is simply a tube graded into 100 divisions. It is 
placed upright, and filled with milk, and the number of divisions occupied 
by the cream indicates its proportion in 100 parts. The lactoscope is 
another instrument employed for the purpose of ascertaining the richness 
of the milk. It consists of two concentric tubes, which move upon each 
other. Milk which we wish to examine is poured within the tubes sufficient 
to obscure a light viewed through it, three feet distant. The column of 
milk is then diminished, till the light begins to be visible. The size of the 
column indicates the degree of opacity and the richness. The lactoscope 
was invented by M. Donne, and is described by him. 

Dr. Minchin recommends a simple mode of determining the richness of 
cow's milk, and it would equally answer for the breast-milk. A vessel 
holding about one ounce, and containing a graduated enamel slab, passing 
diagonally from above downwards, is filled with milk. It is then covered 
with a glass slide carried over it in such a way as to exclude bubbles. 



EXAMINATION OF THE MIT.K. 49 

The number of degrees which can be read, indicates the character of the 
milk, as regards its richness. 

Examination of the milk with the microscope not only enables us to de- 
termine whether there are abnormal corpuscles or granular elements, but 
also its richness. It should be examined before the cream has separated. 
Oil-globules of small size, and few, indicate poverty of the milk ; very large 
oil-globules are said to indicate milk which is apt to be indigestible, espe- 
cially hi feeble infants. Such are the free globules of the colostrum. 
Numerous oil-globules of medium size indicate nutritious milk. Vogel, 
in 1850, made the discovery of vibriones in human milk. The fact is 
established that these animalcules may be generated in the milk within 
the breast, though such cases are not frequent. Dr. Gibb describes a case 
which he met. {Banking's Abstract, vol. xxxiv.) An infant, 7 weeks old, 
wet-nursed by its mother, who had the appearance of perfect health, was, 
nevertheless, ill-nourished and emaciated. It had no diarrhoea or other 
apparent disease, and the milk was therefore examined. Vibriones baculi 
were found in the milk immediately after it was obtained from the breast. 
The milk had the usual amount of cream, and seemed to the naked eye of 
good quality. According to Dr. Gibb, two genera of microscopic organisms 
occur in the milk, namely, vibriones and monads. It is believed that the 
monads occur in consequence of fermentation of the sugar and the produc- 
tion of lactic acid. Vogel also attributed the production of the vibriones to 
fermentation occurring in consequence of heat and congestion of the breast, 
connected with sexual excitement. This explanation is probably not correct, 
because vibriones sometimes occur when there is no unusual heat of breast, 
and no evidence of fermentation. The fact that such organisms may occur 
in milk which seems of good quality to the naked eye, affords additional 
proof of the usefulness of the microscope in the selection of a wet-nurse- 
Many wet-nurses have a return of the menses as early as the fourth or 
fifth month after 'delivery. The re-establishment of this function in some 
women impairs the quality of the milk, so as to render it less nutritious, 
and perhaps less digestible ; in other women it does not sensibly affect the 
character of the fluid or its quantity. In the selection of a wet-nurse, 
then, preference should be given to one who does not have the periodical 
sickness, but if she is already employed, and gives satisfaction, the reap- 
pearance of the catamenia does not indicate the need of a change of nurse, 
unless the digestion of the infant is disordered, or its nutrition is impaired. 
In the selection of a wet-nurse attention should also be given to her 
mental and moral traits. Cheerfulness, affection, veracity, and a proper 
appreciation of the responsibility of her situation, enhance greatly the 
yalue of a wet-nurse. Not less important are habits of temperance and 
cleanliness. I could cite cases of the most melancholy results from the 
absence of these traits. In one case idiocy resulted from an infant falling 
upon the pavement from the arms of a reckless or intemperate wet-nurse. 



50 COURSE OF LACTATION — WEANING. 

lu most cases the mode of examination indicated above suffices to show 
the character of a wet-nurse, so far as her health and milk are concerned. 
It sl)ould be borne in mind, however, that the microscope does not always 
reveal deleterious properties in the milk. Elements which are in a state 
of solution, and are invisible, may occur in excess, so as to impair the 
quality of the milk and render it indigestible. The following case, in 
which the saline ingredients seem to have been in excess, is related by 
Dr. Hartmann {British and Foreign Medical Review, vol. xii) : "An 
infant, whose mother was in good health and had borne several children, 
exhibited a healthy appearance for the first five weeks after birth. The 
alvine evacuations then became copious, fluid, and discolored, and the 
child lost flesh and sti-ength. After the usual remedies had been vainly 
administered for a fortnight, the mother remarked that the child did not 
take the right breast willingly, and so much did the unwillingness in- 
crease, that at length the mere application of the nipple to the child's 
lips occasioned loud crying. On examination it was found that the milk 
of the right breast had a distinctly saline taste ; whereas the milk of the 
opposite breast was of the ordinary sweetness ; no difference of consistence 
or color was discoverable. From that time the child was only allowed to 
nurse the left breast, and in a few days all diarrhoea and sickliness of ap- 
pearance vanished." In this case there was no appreciable disease of the 
breast, although its secretion was perverted. The deleterious character of 
the milk was discovered, not by any change in its appearance, but by the 
taste. 



CHAPTER VI. 

COUKSE OF LACTATIOX— WEANING. 

Regularity in nursing is required. The young infant in whom the 
milk is rapidly assimilated may take the breast every two hours in the 
day and two or three times in the night. Still, as M. Donne has said, 
mathematical exactness in this matter would be ridiculous. Quiet, natu- 
ral sleep of a well-nourished infant should not be interrupted in order to 
give it the breast, unless the sleep be unusually protracted. It will usu- 
ally awaken when the system requires more nutriment. Ill-nourished 
infants, according to my observations, sleep but little until they become 
much prostrated, when they are drowsy, in consequence of passive con- 
gestion of the bi'ain. This drowsiness is evidently a pathological symp- 
tom. It shows the need of increased nutrition. It is due to scantiness of 
milk, or milk of poor quality, and the infant should be aroused frequently 
for the purpose of giving it nutriment or even stimulants. 



COURSE OF LACTATION — WEANING. 51 

As the infant grows older the stomach receives a larger amount of milk, 
and it should nurse less frequently. The breast-milk is sufficient for its 
nutrition till the age of six or eight months, provided it is abundant and 
of good quality. If the mother is strong, and experiences no exhaustion 
from suckling, the infant, therefore, need receive no other nutriment till 
that age, or indeed till the age of ten or twelve months. 

Many mothers, however, by the third or foui^th month of lactation, find 
that they have not sufficient milk to meet the wants of the infant. The 
constant drain upon their systems sensibly impairs their health. In such 
cases it is proper to commence with a little feeding from the spoon or 
bottle, and increase the quantity given as the infant grows older. Great 
care is, however, requisite in the preparation of food for so young an 
infant, whose digestive organs are still feeble and easily deranged. In 
the country, where diarrhoeal affections and the so-called gastric derange- 
ments are not frequent, the danger from artificial feeding is less than in 
the city, and in the cool months in the city the danger is less than in the 
summer season. Infants of the city, between the months of May and 
October, have a strong predisposition to diarrhoeal attacks, the result of 
anti-hygienic influences which surround them. Errors of diet in their 
case readily provoke disease or derangement of the digestive organs, often 
of a severe and dangerous form. Moreover, experience has shown that 
these infants, if fed with the bottle, however carefully, during the period 
when nature designed that they should be nourished by lactation, very 
commonly are affected in the hot months with more or less vomiting and 
diarrhoea, followed by emaciation and other evidences of mal-nutrition. 
Therefore, an exception must be made, in case of the city infant, as re- 
gards the commencement of artificial feeding. If it is under the age of 
one year it should be nourished exclusively, or almost exclusively, at the 
breast during the hot mouths, when practicable, even if the mother suffers 
somewhat in her health from the constant drain upon her system. The 
infant should, however, receive the amount of nutriment which it requires, 
and, if there is not sufficient breast-milk, it will be necessary to supply 
the deficiency by artificial feeding. The reader is referred to Chapter VII 
for facts relating to the subjects of artificial feeding. 

Except, therefore, under the especial conditions of summer heat and city 
residence, the infant at the age of six or seven months may be allowed plain 
cow's milk, Hawley'sLiebig's infant food. Ridge's food, or wheat flour pre- 
pared by long boiling (as recommended in Chapter VII). At six mouths 
also, or even at four or five months, if it appear somewhat an?cmic apd ill 
nourished, it may be allowed occasionally one or two teaspooufuls of beef- 
juice expressed from slightly boiled beef two or three times daily. At the 
age of eight months semi-liquid food may be given. Pap, prepared w'ith 
stale bread or a rolled soda-cracker, may also be given once or twice daily, 
between the times of nursing, and occasionally beef tea or chicken-broth, 



52 ARTIFICIAL FEEDING. 

thickened with cracker or bread, is taken with relish, and if well prepared 
and given no oftener than once or twice a day, it is commonly readily di- 
gested while it is highly nutritious. If the quantity of breast-milk dimin- 
ishes, as it often does, towards the close of the first year, artificial food should 
be given oftener, so as to supply the deficiency. Solid food requires con- 
siderable development of the digestive organs for its ready assimilation. It 
should not, therefore, be given till the close, or near the close of the first year. 
Weaning ought to take place, as a rule, between the ages of twelve and 
eighteen months. It is well, if the mother's health is good and her milk 
is sufficient to defer weaning till the canine teeth appear. The infant then, 
possessing sixteen teeth, is able to masticate the softer kinds of solid food. 
Weaning should be gradual. Mothers often speak of weaning on a cer- 
tain day. They have given but little artificial food, and have suckled at 
regular intervals, till at a fixed time they have denied the breast alto- 
gether. This abrupt change of diet should be discouraged. It should 
only be recommended under peculiar circumstances. It is apt to de- 
range the digestive organs, and it causes fretfulness and sleeplessness on 
the part of the infant for a week or more. Weaning should commence by 
feeding with the spoon, a little oftener through the day, and nursing less, 
and by discontinuing the practice of suckling at night. The infant tole- 
rates this gradual change of diet, while it rebels against sudden weaning, 
and by its fretfuluess increases greatly the care and trouble of the mother. 
The infant in the city should not be weaned in warm weather, nor within 
a month immediately preceding it. If the mother's health fails, or her 
milk becomes deficient in the summer months, so that she cannot continue 
suckling, the infant should be sent immediately to the country, or a wet- 
nurse be employed. Many infants are sacrificed in consequence of igno- 
rance of the danger of weaning under the circumstances mentioned. Severe 
diarrhoea, inflammatory or non-inflammatory, is apt to result. This sub- 
ject will be considered elsewhere. 



CHAPTER VII. 

ARTIFICIAL FEEDING. 

Occasionally the mother is unable to suckle her infant, and a hired 
wet-nurse cannot be or is not obtained. Artificial feeding is then neces- 
sary. In the large cities, if I may judge from our New York experience, 
this mode of alimentation for young infants should always be discouraged. 
It generally ends in death, preceded by evidences of faulty nutrition. A 
considerable proportion of those nourished in this manner thrive during 
the cool months, but on the approach of the warm season they are the first 



ARTIFICIAL FEEDING. 



53 



to be affected with diarrhoea and other symptoms indicating derangement 
of the digestive function. In my opinion, based on a pretty extended 
observation, more than half of the New York spoon-fed infants, who enter 
the summer mouths, die before the return of cool weather, unless saved by 
removal to the country. In the country, and in the small inland cities, 
the results of artificial feeding are much more favorable. The majority live, 
and in elevated farming sections on account of the salubrity of the air, 
and the facility with which milk, fresh and of the best quality, is obtained, 
artificial feeding appears to be nearly as favorable as wet-nursing. 

Young infants, fed by the hand, obviously require food prepared so as 
to resemble as closely as possible the human milk. The basis of such food 
must, therefore, be the milk of some animal. The following table, pre- 
pared by MM. Vernois and Becquerel, gives the proportion of the ingre- 
dients of human milk, and the milk of the four domestic animals which 
is most easily obtained and most frequently employed as food. 



Composition of Milk. 





Specific 
gravity. 


100 parts contain 


Tlie solid components consist of 




Fluids. 


Solids. 


Sugar. 


Butter. 


Casein and 
extractive 
matters. 


Salts. 


Man, .... 
Cow, .... 
Ass, .... 
Goat, .... 
Ewe, .... 


1032.67 
1033.38 
1034.57 
1033.53 
1040.98 


889.08 
864.06 
890.12 
844.90 
832.32 


110.92 
135 94 
109.88 
155 10 
167.68 


43.64 
38.03 
50 46 
36.91 
39 43 


26.66 
36.12 
18.53 
56.87 
54.31 


39.24 
55.15 
35 65 
55.14 
69.78 


1.38 
6.64 
5 24 
6.18 
7.16 



Cow's milk is most readily obtained, and is commonly used as a substi- 
tute for human milk, compared with which it contains less water and sugar, 
but more butter, casein, and salts. Its composition, however, varies con- 
siderably according to the food of the cow and other circumstances. The 
variations in the milk of the cow, according to the nature of its food, have 
been considered in a preceding chapter. It has been stated also, that the 
milk first obtained in milking is most watery, since it is longer secreted 
than the last milk, or the "stripping." The stall-fed cow gives acid milk, 
while the cow grazing in a pasture gives milk that is alkaline. Again, 
the milk in the first months after calving is richer than after the lapse of 
several months. 

It is obvious from the above facts that the analysis of different speci- 
mens of cow's milk must differ greatly, and the same is true of the milk of 
the goat and ass, and probably of the ewe. In fact, different samples of 
the milk of the same animal may differ more from each other, in their 
chemical character, than the average milk of one animal from that of an- 
other. 



54 ARTIFICIAL FEEDING. 

The milk of the goat and that of the ass have been recommended as 
food for infants in preference to cow's milk, on the ground, as is alleged, 
that they more nearly resemble human milk. But by reference to the fore- 
going table it will be seen that more importance has been attached to this 
supposed resemblance than the fjicts justified. Neither the milk of the ass 
nor goat, so far as its chemical character is concerned, would seem to pos- 
sess any advantages over cow's milk. The ass's milk is procured with dif- 
ficulty, and is seldom used. An objection to goat's milk is the unpleas- 
ant odor which it often possesses, due to the presence of hircic acid. It is 
stated, however, by Parraentier, that this odor is only noticed in the milk 
of goats that have horns. An important advantage, in the city, in the use 
of goat's milk, is that the animal can be kept at little expense, so that even 
poor families who are not able to purchase and feed a cow, can generally 
possess a goat from which fresh milk can be obtained at any time. Pref- 
erence is to be given to goat's milk, when fresh, over cow's milk brought 
from the country, perhaps watered on the way, and several hours old 
wheu received. If, however, as both chemical analysis and experience 
show, goat's milk is no better as food for infants than cow's milk when 
fresh and from healthy cows, the latter must continue in common use for 
this purpose. 

Milk used for infants should always be alkaline. If it is acid, as shown 
by the proper test, it should be rejected; or, if there is none better, should 
be rendered alkaline by the addition of lime-water or carbonate of soda. 
The nurse should test the milk at different periods through the day, and 
be taught to make the necessary addition. M. Donne prefers the first 
milking, when it is possible to obtain it. This contains a smaller propor- 
tion of solid elements than the average milk, bears a closer resemblance 
in its chemical character to human milk, and requires but little dilution. 
The upper third of the milk, after it has stood two or three hours, is also 
preferable, as the casein, which is digested with more difficulty than the 
other elements, has a high specific gravity, and tends to settle towards the 
bottom. If the infant is under the age of two or three months, the milk 
should be diluted with one-fourth its quantity of water. After the age of 
three or four months it requires no dilution. It should always be given at 
a uniform temperature, namely, a little warmer than the body. Employed 
habitually too hot or too cold, it is apt to cause stomatitis, if not more 
serious disease of the digestive organs. 

A little pulverized sugar of milk, which is now kept in the shops of the 
city, and is slowly soluble, may be dissolved in water, and added to the 
milk. One drachm of the sugar is sufficient for five or six ounces of the 
milk. An alkali taken with cow's milk retards the coagulation of casein 
in the stomach, and tends to prevent the formation of large and thick 
curds in this organ, which are with difficulty digested, and are apt to give 
rise to gastric or gastro-intestinal derangement. If, therefore, the child 
vomits such curds, or passes fragments of them in the stools, or if the 



ARTIFICIAL FEEDING. 55 

stools are acid, lime-water may be added, or the carbonate of soda, as 
recommended by Vogel, who dissolves one drachm of the carbonate in six 
ounces of water, and adds a teaspoonful to the milk at each meal. 

It has been customary in families to give bottle-fed infants various kinds 
of farinaceous food, as arrowroot, wheat, rice, and barley-flour in addition 
to the milk. But infants, prior to the age of four months, are able to di- 
gest only a small quantity of starch, for the glands which secrete the fluid 
by which starch is digested, namely, the salivary and pancreatic, are very 
small, almost rudimentary prior to the fourth mouth. Certain glands, 
whose functions are important in the life of the individual, are small, and 
have but little activity in the first weeks or months of life. Such are the 
lachrymal and intestinal glands in addition to the salivary and pancreatic. 
After the third month tears appear, and the quantity of saliva which pre- 
viously was very small is more abundant, and it increases as the child 
grows older. After the third or fourth month not only is there a moi'e 
rapid growth of the salivary glands and pancreas than previously, but also 
probably a greater functional activity. In a recent monograph relating 
to Infant Diet, written by Prof. A. Jacobi, and revised, enlarged, and 
adapted to popular reading by Dr. Mary Putnam Jacobi, it is stated that 
the parotid glands which combined weigh, at fifteen months, 80 grains, 
and 120 at two years, weigh but 34 grains at the age of one month. In 
sevei'al instances during the present year (1875) we weighed the pancreas 
taken from the bodies of infants who had died under the age of six months 
in the New York Infant Asylum. The weight was very different in those 
whose ages were about the same; in several under the age of four months it 
was less than one drachm, and in some more than one drachm; but in no 
instance did it reach two drachms. Now it is evident, since the parotids 
and pancreas chiefly secrete the liquid by which starch is digested, for the 
submaxillary and sublingual glands are comparatively insignificant, that 
those kinds of food which consist largely of starch are innutritious, and 
therefore unsuitable for very young babies (see paper by Sonsino, of Pisa, 
in London Practitioner, Sept. 1872). 

If, however, we convert the starch, or a considerable part of the starch 
into sugar, or sugar and dextrin, we have a food which is more easily di- 
gested, and may be given safely to infants under the age of three months. 
Liebig's food is such a preparation. It is made in this country under the 
intelligent supervision of Dr. Hawley, of Brooklyn, and is kept in the 
shops under the name of Hawley's Liebig's food. 

The accompanying statements show us the nature of Liebig's food, and 
the way in which it is made. Starch is transformed into sugar and dextrin, 
a change which, when farinaceous substances are used in the usual way, is 
effected in the stomach, and thus this organ is relieved from a part of the 
burden of digestion. 

" The following is the best way of preparing this food : Half an ounce of 



56 ARTIFICIAL FEEDING. 

wheaten flour, and an equal quautity of malt flour, seven grains and a 
quarter of bicarbonate of potash, and one ounce of water are to be well 
mixed ; five ounces of cow's milk are then to be added, and the whole put 
on a gentle fire. When the mixture begins to thicken, it is removed from 
the fire; stirred during five minutes; heated and stirred again, till it be- 
comes quite fluid, and finally made to boil. After the separation of the 
bran by a sieve, it is ready for use. By boiling it for a few minutes, it 
loses all taste of the flour." — {Lancet, January 7th, 1865 ; Braithwaite's 
Retrospect, July, 1865.) 

This food, according to Liebig, furnishes double the amount of nutriment 
contained in milk, or as he expresses it, is a " double concentration " of that 
secretion. 

Dr. Hassell, in a communication in reference to this food to the Loudon 
Lancet for July 29th, 1865, says : " It appears to me that the great merit 
of Liebig's preparation consists in the use of malt flour as a constituent of 
the food ; this, from the diastase contained in it, exercises, when the fluid 
food or soup is properly prepared, a most remarkable influence upon the 
starch, quickly transforming it into dextrin and sugar, so that in the course 
of a few minutes the food, from being thick aud sugarless, becomes com- 
paratively thin and sweet." 

..." Correct and ingenious as are the principles upon which this food 
has been designed, yet the directions given for its preparation are certainly 
open to considerable improvement. Thus, Liebig directs that the malt 
should be ground in a common cofiee-mill, aud the coarse powder passed 
through a sieve. This necessitates the subsequent straining of the food, a 
tedious operation, in order to remove the bran and remaining particles of 
husk. And further, that the food should be put upon a gentle fire previous 
to its being finally boiled. Now, a gentle heat may mean almost any 
temperature neai'ly up to the boiling-point ; and since the action of the 
diastase is destroyed at about 150^ F., the temperature should never be 
allowed to exceed that degree. 

" I recommend, therefore, that the malt should be well freed from husk, 
and finely ground ; that the wheat flour should be lightly baked ; and 
finally, that a thermometer should be employed in the preparation of the 
food. Indeed, in some samples recently submitted to me by Messrs. Sa- 
vory and Moore, I find that the first two points have been attended to, and 
that they use malt freed from husk and finely ground, and the wheat flour 
baked. 

"The effect of baking the wheat flour is to partially cook the starch 
entering into its composition, so that less heat is required in the prepara- 
tion of the liquid food. I find that a temperature ranging between 140° 
and 148° is amply sufficient to effect the complete transformation and solu- 
tion of the starch-corpuscles, and, indeed, to cook the food sufficiently." 

Dr. James S. Hawley, who has given much attention to the prepara- 



I 



AETIFICIAL FEEDING. 57 

tion of Liebig's food, and who now furnishes the market with it, says : 
" The principal objection which has been urged against Liebig's food is the 
difficulty of its preparation. This objection certainly did lie against the 
process recommended by its author, and against many of the directions 
since proposed. But . . . the simplest form of cooking is all that is 
requisite. This consists in mixing the dry food, properly compounded, 
with milk or water (better milk), and slowly bringing it to a boil with 
frequent stirring ; or heating it until it begins to thicken, then remove it 
from the fire and stir until it grows thin, and repeat this process two or 
three times. At the close of the process it will be quite thin and sweet. 
No food can be cooked in a simpler manner than this. This dissolving of 
the thick hydrated starch is itself the evidence of the transformation of 
amylum into glucose. It is not claimed, that by this simple method, all 
the starch is converted, but that its percentage is very greatly diminished, 
sufficiently so to afford abundant assimilable nutriment to the infant, and 
also to avoid the dangers and inconveniences arising from the presence of 
indigestible matter in the intestines." 

In Ridge's food, although the manner in which it is made is kept secret, 
I suspect that a somewhat similar change of the starch has been effected. 
We are informed that it is made from wheat flour, and it certainly agrees 
with the youngest infants, as I have many times observed. It contains, 
however, considerable starch, as is shown by the iodine test. Again, if we 
crowd snugly in a small muslin bag one to two pounds of the best wheat 
flour, boil it forty-eight hours in water sufficient to cover it, and then when 
it dries grate the flour from it, we obtain what closely resembles Ridge's 
food. These three kinds of flour are employed in the New York Infant 
Asylum with a satisfactory result, but the preference is given to Ridge's 
food, which seems to agree with the largest number. 

In the first half year it is most convenient and is otherwise preferable to 
employ the nursing-bottle, after which the infant may be fed with a sj^oon, 
or taught to drink from a cup. The bottle and tip, when not in use, should 
be placed in a bowl of cold water containing a little bicarbonate of soda, 
one teaspoonful to the pint. 

The physician should positively forbid the use of sugar teats and vari- 
ous sweetened admixtures which nurses are so apt to employ, as they tend 
to produce the common forms of stomatitis, and, if much employed, even 
indigestion and diarrhcjea. 

Between the ages of o)ie and two years the teeth have become sufficiently 
developed for the mastication of liglit food. Tender and finely cut meat, 
potato baked and mashed, bread and butter, aud even certain fruits care- 
fully selected, may then be allowed. After the age of two years less rigid 
surveillance of the food is required, but the variety is sufficient if all 
dishes except the most bland and unirritating are excluded till after the 
first years of childhood. 



58 BATHS — CLOTHING. 



CHAPTEK YIIL 

BATHS— CLOTHING. 

Daily ablution of the iufant conduces to its comfort and health. If 
under the age of two months, it should be bathed daily in water of about 
the temi)erature of 92^. As it grows older the temperature should be 
gradually reduced, a bath at 88° to 90° being proper for an infant between 
the ages of three and six months, and one at 86° for an infant between six 
and twelve months. In the second and third years the temperature of the 
bath should be about 84°. After the bath, which should continue from 
five to ten minutes, the surface should be gently rubbed with a soft towel 
to produce reaction and a glow of the skin, which would prevent clanger 
of taking cold. 

The clothing of children, especially in our variable climate of the north, 
is a matter of importance, and one in regard to which the parents often 
require instruction. It may be stated, as a rule, that the chest and abdo- 
men of the infant should be so covered with flannel that there is no danger 
of producing chilliness by a sudden reduction of the external tempera- 
ture or exposure to a current of air. By this precaution many cases of 
laryngitis, bronchitis, and diarrhoeal affections, now so common in infancy, 
might be avoided. In winter the flannel should be thick, and in the sum- 
mer thin. Even in the hottest weather the abdomen should have a light 
flannel covering, which increases the comfort, if the surface is in the nor- 
mal state. If lichen, which is not uncommon in the warm months, ap- 
pear upou the surface, I would not remove the flannel, but place under it 
linen or soft muslin. 

The popular idea that children may be hardened by exposure to the 
weather in scanty clothing, and by being bathed, even at the most tender 
age, in water at so low a temperature as to produce chiliness, cannot be 
too strongly combated. The hygienic management of the child should 
always be such as insures present comfort. If it do not, if it is regarded 
with aversion and dread by the child, the method is wrong. 

The dress should always be so loose as to allow free movements, and not 
embarrass in the least any of the functions. This is a matter which is left 
too much to the discretion and intelligence of the nurse, who is usually so 
ignorant of the important facts in physiology that she unwittingly, and 
with the best intentions, injures her charge. I have often interposed to 
loosen the dress of the new-born, wdiich was so tight as to sensibly embar- 
rass respiration; and one case has been reported to me in which it appeared 



APNCEA NEONATORUM. 59 

that death resulted from this cause. Infants, especially, who are so liable 
to pulmonary collapse and intestinal hernias, should have loose covering 
of both chest and abdomen. 

The feet of children should always be warm. Infants require flannel 
stockings, thick or thin, according to the, season. Care should be taken 
that the shoes produce no compression, and they should be exchanged for 
those of a larger size as often as is required by the growth of the feet. 
Deformity of the feet or toes, ingrowing toe-nail, and induration of the 
skin, can sometimes be traced back to tightness of a shoe in childhood. 

Physicians are so well aware of the importance of domiciliary cleanli- 
ness and ventilation, of the free admission into the nursery of solar light, 
and of the importance of outdoor exercise as a means of invigorating the 
system and promoting healthy functional activity, that nothing need be 
stated in reference to these subjects in this connection. 



CHAPTER IX. 

ACCIDENTS AND AILMENTS INCIDENTAL TO THE BIRTH OF THE 
INFANT, AND DETACHMENT OF THE COKD. 

Apncea (Asphyxia) Neonatorum. 

In the healthy infant, born under favorable circumstances, the two im- 
portant functions of life, respiration and circulation, are established within 
the first minute. But it not infrequently happens, in consequence of some 
unfavorable circumstance, that the heart and lungs fail to act, and the in- 
fant lies motionless as one dead. Sometimes in these cases an occasional 
pulsation of the heart can be detected Avhen the fingers press under the left 
ribs, but there is no respiration. According to the nature of the cause, 
the surface is exsanguine or cyanotic and livid. 

Causes. — These are various. The fault may be partly in the infant ; it 
may be feeble in its development; but the common causes are compression 
of the cord during birth, from breech presentation or otherwise, powerful, 
frequent, and long-continued uterine contractions, often induced by ergot, 
but sometimes occurring normally, which compress the placenta, and con- 
sequently obstruct the i'cetnl circulation ; detachment of the placenta be- 
fore birth, and protracted labor, from pelvic iiialformation or otherwise, 
even when there is no unusual severity of the pains. 

TREATME>rT. — Obviously the treatment must be prompt. Mucus should 
be removed from the mouth and fauces with the finger, and, except in those 
cases in which there has been placental hemorrhage or au.Tmia from other 
causes, as exhibited by pallor of the surface, a few drops of blood should 



60 APNCEA NEOXATORUM. 

be allowed to ruu from the cut extremity of the cord. The flow induced 
aids iu establishing the circulation, and, in the large proportion of cases in 
which there is congestion of the internal organs, gives partial relief to it. 
Brisk rubbing of the body, slapping the buttocks, blowing in the face, 
sprinkling water upon it, alternately transferring the body from a tub of 
hot to cold water, may be tried in quick succession, and, if there are no 
signs of returning animation, no time should be lost iu resorting to arti- 
ficial respiration. ' 

The child should be placed on its side upon the edge of a table, with a 
blanket underneath it, and the head in such a position that the epiglottis 
falls forward ; a towel or napkin should be placed over its face, having a 
hole of sufficient size to blow through corresponding with its mouth. The 
physician compressing firmly the epigastrium with his thumb, blows a full 
breath through the hole. A little of the air, notwithstanding the com- 
pression, enters the stomach, some may escape by the nostrils, and the rest 
enters the lungs. Immediately, the hand passing from the epigastrium to 
the thorax, compresses it gently though with sufficient force to produce ex- 
piration. This should be repeated six or eight times per minute. The ac- 
tion of the heart, previously slow, becomes quicker by the artificial respira- 
tion. I have been able to produce pulsations by this method when the 
heart had ceased to beat for a considerable time, and death, to all appear- 
ance, had occurred. Some recommend placing the infant on the right side, 
on account of the position of the valve between the auricles, but I think it 
is better to change it from one side to the other, in order to prevent con- 
gestions, which are so apt to occur when the circulation is imperfect. The 
circulation always commences sooner than respiration. The first respira- 
tions are mere gasps, not more than one or two per minute in cases of de- 
cided asphyxia, but as they become more frequent they are also deeper. 

Artificial respiration should be continued fifteen or twenty minutes in 
cases in which no action of the heart can be detected by pressing the fingers 
under the ribs, when, if there are no signs of returning animation, the case 
is hopeless. If there is any pulsation, however feeble, we should not cease 
in the attempt at resuscitation. Some prefer insufflation tlu'ough a tube 
(as the segment of a catheter) introduced into the larynx, and pressure 
upon the thyroid cartilage so as to close the pharynx, instead of upon the 
epigastrium. The principle of treatment is similar, but the mode which 
I have recommended above I have found successful beyond expectation. 
Thus, in one case in my practice in which pulsation in the umbilical cord 
had ceased from ten to fifteen minutes before birth in consequence of its 
prolapse, I employed artificial respiration nearly a quarter of an hour be- 
fore there was any appreciable pulsation, but by perseverance the circula- 
tory and respiratory functions wei'e fully re-established, and the child lived 
and was vigorous. When respiration commences insufflation may cease, 
but it is proper to aid the respiratory movements a little longer by com- 
pressing the thorax after each inspiration. Still, the physician may be dis- 



CAPUT SUCCEDANEUM. 61 

appointed in the result. In not a small proportion of cases the respiration 
continues gasping, and after a few hours, perhaps even a day, death ensues. 
I have made post-mortem examination of several infants who have died 
under such circumstances, chiefly in the Nursery and Child's Hospital, about 
six from recollection, and have found considerable uniformity in the appear- 
ance of the viscera. Only a small portion of the lungs, sometimes almost 
none at all, was found inflated, even when the cries had for a time been 
strong, and extravasated blood usually in considerable quantity lay upon 
the surface of the brain, evidently having escaped from the meningeal 
vessels, which were in a state of extreme congestion in consequence of the 
protracted or difficult birth. Meningeal apoplexy therefore seems to me 
the chief cause of the ill-success attending our efforts to save those Avho are 
so far resuscitated as to be able to breathe. 

Recently, Prof. H. L. Byrd, of Baltimore, has recommended a simple 
mode of resuscitation. The physician places his hands under the middle 
portion of the back of the child, with their ulnar borders in contact, and 
at right angles to the spine. Extending his thumbs, he carries forwaixi the 
two extremities of the trunk by gentle but firm pressure, so that they form 
with each other an angle of about 45° in the diaphragmatic region. Then 
the angle is reversed by carrying backward the shoulders and the nates. 
An assistant may aid by supporting the head. By alternating these move- 
ments, Prof. Byrd has succeeded in effecting resuscitation when other 
methods had failed, and when so much time had elapsed that the case 
would seem hopeless to most practitioners. The name and position of Dr. 
Byrd commend this method to consideration and trial. (American Supple- 
ment of Obstet. Jour, of Great Britain and Ireland, 1873.) 



Caput Succedaneum— Cephalaematoma. 

During the birth of the child, extravasation of blood not infrequently 
occurs in the part of the scalp which presents. This results from the 
passive congestion, more or less intense according to the duration of labor 
and severity of the labor-pains, which occurs in the presenting part, 
whether scalp, arm, or breech. Caput succedaneum is the term em- 
ployed to designate the swelling thus caused. Its seat is the loose con- 
nective tissue of the scalp external to the pericranium. The tumor is soft, 
painless, and usually located upon the occiput. It consists partly of ex- 
travasated blood, but largely of serum which has transuded from the con- 
gested vessels before that degree of congestion was reached required to 
effect tlie transudation of the corpuscles. I have repeatedly had an oppor- 
tunity to examine this tumor in stillborn inffxnts brought from the lying- 
in wards attached to the Nursery and (child's Hospital, and have found 
when it was slight that it consisted almost entirely of serum, but ordinarily 
when dissected it presented the appearance of a bruise, with a large pro- 



62 CONJUNCTIVITIS NEONATORUM. 

portion ofscMiim, the blood and serum infiltrating the scalp to a greater or 
less distance beyond the appreciable limits of the tumor. Caput succe- 
daneum requires no treatment. As it lies in the loose connective tissue of 
the scalp, its liquid permeates the open areohie in every direction, to be 
rapidly absorbed, while the tumor disappears. The subsidence of the 
swelling is usually complete within forty-eight hours. 

Occasionally blood is extravasated under the pericranium, detaching it 
from the bone. This occurs in connection w'ith caput succedaneum, and 
is observed when the latter declines. The tumor thus produced is desig- 
nated cephalcematoma. It is situated upon the occipital or parietal bone, 
near the posterior fontanelle. Its base corresponding with the denuded 
bone is circular or oval, and it rarely crosses a suture. In rare instances 
two cephalsematomata occur, located upon the occipital and one parietal, 
or upon both parietal bones. The liquid, being surrounded by the firmly 
attached pericranium, does not escape in the surrounding tissues, as the 
caput succedaneum, and is therefore much more permanent. It flattens 
slowly by absorption, and does not disappear till after several weeks. At 
the age of six months a slight prominence can sometimes be detected, in- 
dicating the seat of the tumor. As the pericranium elevated by the blood 
does not lose its vitality, it soon begins to produce bone, so that after some 
days a ring of new bone can be detected by the finger surrounding the base 
of the tumor, and on the inside of the detached membrane a layer of bone 
is produced, thin at first and flexible, but gradually approximating the old 
bone, and becoming firmer as absorption occurs. 

Some time since, a specimen was presented by me to the New York Path- 
ological Society, showing this accident and the mode of cure. The child 
died about two months after birth, and the blood constituting the tumor, 
which had been in great part absorbed, was completely incased by the old 
bone below and the new thin formation above. The cavity at length be- 
comes obliterated, and there only remains some thickening of that part of 
the cranium which corresponds with the location of the tumor. 



CHAPTER X. 

CONJUNCTIVITIS NEONATORUM. 

Inflammation of the conjunctiva in the new-born is not an unusual 
disease. We distinguish two forms of it, differing in gravity. It com- 
mences in the first week, and commonly about the third day. 

Causes. — The causes of conjunctivitis neonatorum are not the same in 
all cases. The ^rave form, which has been designated purulent ophthalmia, 



CONJUNCTIVITIS NEONATORUM. 63 

has been known to occur during epidemics of puerperal fever, probably 
from the epidemic influence. Another cause, one which is easily under- 
stood, and which is universally recognized by the profession, is the intro- 
duction under the eyelids, during the birth of the child, of a particle of 
the vaginal secretion of the mother. The ordinary leucorrhoeal, and still 
more gonorrhoea], secretion has this effect. Moreover, all accoucheurs meet 
occasionally sporadic cases in cleanly and highly respectable families, oc- 
curring from some unknown cause, though perhaps in a certain proportion 
of these cases also a little of the leucorrhoeal discharge coming in contact 
with the conjunctiva has produced the inflammation. Certainly in pri- 
vate practice gonorrhoeal infection is in only a small proportion of cases 
the cause of purulent ophthalmia of the new-born. Some observers, as 
Professor Gross, believe that the most frequent cause of purulent ophthal- 
mia of the new-born is atmospheric. 

The causes of the mild form are different also in different cases. Promi- 
nent among them are bad hygienic conditions, exposure of the eyes to a 
current of cold air, and the introduction of a little of the vernix caseosa 
or soap under the lids in the first "washing. 

Symptoms. Severe Form. — In the beginning the palpebral conjunctiva 
is observed to be red, a little swollen, and its cutaneous surface presenting 
a faint reddish tinge. The light appears to be painful, and the child is 
fretful and sleeps but little; but the eye itself presents its normal appear- 
ance. The progress of the disease, however, is rapid, and in twenty-four 
or thirty-six hours there is so much tumefaction that the upper lid extends 
over the lower, and it may be impossible to separate them sufficiently to 
obtain a view of the eye. The tumefaction is due to oedematous infiltration. 
The conjunctiva, both palpebral and ocular, now presents a deep red hue, 
is thickened and swollen, and numerous fine granulations appear upon it; 
occasionally also flakes of very delicate pseudo-membrane can be observed 
in addition. There is an abundant production of pus of a creamy appear- 
ance, sometimes tinged with blood, which oozes out when the lids are sepa- 
rated. A critical period has now arrived, one which may involve the de- 
struction of the cornea unless the case is promptly and judiciously treated. 
Indee(i, the gravity of the disease relates chiefly to the state of the cornea, 
which up to the present time, notwithstanding the severity of the inflam- 
mation and the amount of surrounding infiltration, has remained transpar- 
ent and apparently unaffected. But within another twenty-four hours the 
cornea may lose its polish, and grayish, opaque spots of softening appear 
upon it. Soon perforation occurs, the aqueous humor escapes, and the 
iris falls forward, closing tlie ajierture and preventing further loss of the 
liquids of the eye. 

I have observed destruction of the cornea and loss of sight cliiefly, first, 
in cases of true gonorrhoeal infection, in wliidi lliere is the maximum 
amount of iuflammatiou and tumefaction, extending even over the malar 



64 COXJUXCTIVITIS NEONATORUM. 

bone and supraorbital ridge, with marked redness and elevation of tem- 
perature of the lids; and, secondly, with a less degree of inflammation in 
those who were highly scrofulous. In other cases 1 am of opinion that the 
cornea can ordinarily be preserved with proper treatment, although there 
may be so much purulent discharge and oedema that it may be impossible 
to see it for several days. Occasionally the cornea, instead of sloughing, 
becomes infiltrated to a greater or less extent, and ulcerates, but without 
perforation. As the patient recovers, cicatrization occurs. 

The inflammation soon begins to decline. The swelling, heat, and red- 
ness of the lids and conjunctiva, and the granulations, gradually disap- 
pear, and recovery is complete, except so far as the cornea may have been 
injured. 

Mild Form. — The inflammation is from the first of a mild grade, per- 
taining chiefly to the palpebral conjunctiva, with but a slight discharge of 
purulent matter, and with little swelling or increase of heat in the lids. 
Attention is directed to the complaint chiefly by the secretion which col- 
lects in the angles of the lids or upon their border. There may be slight 
intolerance of light, and ordinarily minute granulations appear upon the 
inflamed mucous surface. This form of the disease may disappear within 
a few days, or it may be protracted. 

The conjunctivitis of the new-born is contagious, some forms of it highly 
so. It commences on one side, and, without precautions, commonly within 
a few days extends to the other. 

Treatment. — As soon as the inflammation occurs, the opposite sound 
eye should be covered with a compress, kept in place by strips of adhesive 
plaster. This eye should be examined, however, once or twice daily, in 
order to detect the commencement of inflammation, and the bandage re- 
applied. 

The mild form of conjunctivitis requires very simple treatment. Fre- 
quently bathing the lids with lukewarm water, or milk and water, so as to 
remove the secretion from between the lids, sufiices in a large proportion 
of cases. Among the poor the mothers ordinarily bathe the lids with 
breast-milk, and by this simple treatment effect a cure. If the inflamma- 
tion should not abate soon by this treatment, a mild collyrium of one- 
foui'th grain of nitrate of silver to one ounce of water should be applied 
between the lids and allowed to run under them. 

The severe form, or purulent ophthalmia, on the other hand, requires 
prompt and judicious management. There is scarcely a disease in which 
delay is more disastrous. 

The frequent removing of the pus is very important, which is confined 
in large quantity underneath the closely compressed lids, and by its pres- 
sure and irritation increases greatly the danger of destruction of the cornea. 
Therefore the lids during the height of the imflammation should be 
pressed apart every hour, so as to allow the pus to escape, and the space 



CONJUNCTIVITIS NEONATORUM. 65 

between the lids be freed from pus by a camel-hair peucil. Occasionally- 
warm water may be thrown under the lids by a small glass syringe, to wash 
away pus and any flakes of pseudo-membrane. Probably three or four 
drops of carbolic acid to each ounce of the water would be beneficial, from 
the known good effect of this agent on suppurating surfaces, but I have 
never employed it. 

Medicinal applications to the inflamed conjunctiva should, in most cases, 
be mild, but should be frequently applied. It is known that Von 'Grafe 
recommended the application of nitrate of silver as a caustic; but this 
is painful and sometimes difficult, for it requires eversion of the lids. I 
much prefer, in the treatment of purulent ophthalmia, the application of 
a weak solution of corrosive sublimate every three hours between and 
under the lids, the pus, so far as practicable, having been first removed by 
the brush and syringe. I employ the following formula, and the result 
has, in my practice, been so favorable that I have not felt justified in try- 
ing another: 

R. Hyd. chlor. corros., gr. j ; 

Aqua3 ro?arum, 51] ; 

Aqute, ^vj. Misce. 

Still, the beneficial result which I have observed in cases treated with 
this collyrium was no doubt largely due to the frequent removal of the pus, 
the importance of which cannot, in ray opinion, be too highly estimated. 
In ordinary or mild cases of purulent ophthalmia, a light poultice of ground 
slippery elm, mixed with sugar of lead water, will be found useful; but if 
there is great heat and swelling of the lids, a preferable application, while 
the inflammation is intense, are pieces of a single thickness or two thick- 
nesses of muslin or linen an inch and a half square, squeezed out of cool 
water or lead-water, and renewed every two or three minutes when they 
begin to be warm. When the inflammation has become less intense, and 
the danger of the destruction of the cornea is past, the poultice or sugar 
of lead wash may be employed instead. The decline of the inflammation 
is gradual, though generally pretty rapid. Occasionally granulations re- 
main upon the lids. If they do not diminish and disappear w^ien the puru- 
lent inflammation has ceased, I would not j^ractice excision, as recom- 
mended by Vogel, but, having everted the lids, apply a solution of nitrate 
of silver, five or ten grains to the ounce, to the granulations, each second 
day, and immediately wash away the solution by a camel-hair pencil with 
lukewarm water, and apply a little sweet oil before the lid is returned. If 
the granulations do not disappear with this treatment, they may be lightly 
touclied with the smooth surface of a crystal of suli)hate of copper, fol- 
lowed by the application of water and sweet oil. ]3y this mode of treat- 
ment, employed from the commencement of the inflammation-, a large pro- 
portion even of the severest cases recover with good vision. 

6 



66 DISEASES OF THE UMBILICUS. 



CHAPTER XL 

DISEASES OF THE UMBILICUS. 

When properly managed, the cord desiccates and falls off between the 
third and ninth days. The nurse should not be allowed to oil it, which 
she will sometimes do unless forbidden, as this retards desiccation. If the 
dressing of the cord is allowed to remain wet from the urine or otherwise, 
the cord does not desiccate, but decomposes. This is not infrequent in 
poor, intemperate, and slovenly families. The decaying cord is apt to 
produce inflammation of the navel. Some Southern physicians, prior to 
the late war, attributed the prevalence of trismus neonatorum among the 
slaves to the lesion of the navel produced by this cause, the trismus being 
then essentially traumatic. 

Inflammation of the Umbilical Vein and Arteries. 

When at birth the cord is ligated, if the child is in its normal state, 
clots form in the umbilical vessels from the navel inwards. Atrophy 
of the vessels follows, and by the twenty-fifth day they are represented by 
small, firm, fibrous cords. Sometimes, though rarely, a true phlebitis or 
arteritis occurs in these vessels in the first days after birth, due either to 
the low vitality of the child and decomposition of the fibrinous plugs and 
gelatinous substance of the cord, or the entrance into the vessels of purulent 
or decaying matter from the fossa of the umbilicus. We are sometimes able, 
by pressing along the abdominal walls towards the umbilicus, to squeeze out 
a few drops of the decaying and purulent substance. The navel itself is 
usually inflamed at the same time. This is a very serious disease. Pus, 
with particles of disintegrated fibrin, is apt to pass along the vessels and 
enter the circulation, and, being intercepted in distant parts, gives rise to 
embolismal inflammations. This seemed to be the cause of several sub- 
cutaneous inflammations, and points of embolismal pneumonitis in a new- 
born infant which I attended in 1868. The infant belonged to a family 
highly scrofulous and prone to scrofulous inflammations. Umbilical phle- 
bitis and arteritis are said to occur most frequently in lying-in institutions 
during epidemics of puerperal fever. 

Treatment. — In the manner already indicated we should attempt 
gently to press out any purulent and decomposing substance from the 
vessels, and the infant should be placed with its abdomen dependent so 
far as it can be done without rendering it uncomfortable, so as to aid in 



INFLAMMATION AND ULCERATION OF UMBILICUS. 67 

the escape of the liquids by gravity. The umbilical fossa should be kept 
clean, and warm water containing a little carbolic acid may be dropped 
upon it several times daily. The abdomen should be covered with a soft 
and warm poultice. 

Inflammation and Ulceration of Umbilicus. 

Inflammation of the umbilicus sometimes occurs in the new-born about 
the time of the detachment of the cord, or soon after. It probably results 
from uncleanliness, or carelessness in the management of the cord, by which 
irritating and decomposing substances remain in the umbilical fossa. Some- 
times decomposing particles from the cord are the probable irritant. This 
disease is also most apt to occur in cachectic infants, or those of scrofulous 
parentage, whose general condition renders them liable to inflammations. 
The umbilicus becomes red, slightly swollen, and moist by a secretion. 
Often the inflammation remains two or three days in this mild form, re- 
ceiving no treatment except from the nurse, and disappearing by the use 
of the dusting-powder which she employs. In other instances, the inflam- 
mation extends over a radius of an inch or even more, the walls of the 
umbilicus become swollen and infiltrated, and ulceration succeeds. The 
ulcer is circular, occupying the site of the navel, and attended by a 
purulent discharge. The inflammation may now gradually abate, and 
the ulcer heal with a cicatrix in place of the umbilicus. But in other 
instances, especially if there is a decided cachexia, the ulcer extends in 
breadth and width, till finally, in the worst cases, the peritoneum becomes 
involved, and pez'foration or peritonitis occurs, with death. 

Under unfavorable hygienic circumstances the blood of the infant being 
vitiated, the ulcer may become gangrenous, or the inflammation may 
terminate directly in mortification, without the formation of an ulcer. In 
either case the prognosis is unfavorable. If a dark-brown slough occupies 
the site of the umbilicus, and a sero-sanguiueous discharge exudes from 
underneath, the common result is perforation, peritonitis, and death in from 
one to two weeks. 

Treatment. — Inflammation of the umbilicus, if at all severe, and espe- 
cially when attended by any destruction of the tissues involved, rapidly 
reduces the strength. In such cases three or four drops of brandy should 
be administered every hour to two hours in the breast-milk. 

In the simple inflammation the navel should be bathed with lukewarm 
water three or four times daily, and the ointment of the oxide of zinc be 
constantly applied ; or if there is little or no discharge, the navel may be 
dusted with the powdered oxide of zinc. In case of ulceration the navel 
should be gently washed three or four times daily with lukewarm water, 
to which carbolic acid is added — three or four drops to the ounce ; and if 
there is much inflammation, a light poultice of pulverized slippery elm 



68 UMBILICAL HiEMORRHAGE. 

should be applied iu the iuterval, or if the inflammation is moderate, the 
balsam of Peru. If gangrene supervene, the parts should be frequently 
bathed with the carbolic-acid-water, and a cloth soaked with it be applied 
over it. The slough should be detached as soon as it is so far separated 
that its removal causes no haemorrhage, after which the treatment for 
ulceration is appropriate. 

Umbilical Granulations or Fungus. 

When the cord falls, granulations sometimes sprout out from the ex- 
posed raw surface, and complete cicatrization is impossible till they are re- 
moved. They form a rounded mass of a pale reddish hue, at the centre of 
the umbilical fossa, bleeding when rubbed, and causing constant moisture 
of the umbilicus. The largest which I have seen had perhaps twice the 
size of a large pea, and they may be of any smaller size. 

Treatment. — By pressing upon the umbilical parietes the tumor rises 
from the fossa, so that a silk ligature can be applied around its base, when 
the mass can be readily removed with the scissors. If the granulations are 
small, they may be removed by the scissors, without the ligature, and 
haemorrhage prevented by touching the surface with lunar caustic. 



CHAPTEK XII. 

UMBILICAL H^EMOKRHAGE. 

The granulations which have been described above sometimes cause con- 
siderable haemorrhage when injured. The profuse and even fatal haemor- 
rhage which occurs at birth, or soon after, from too loose' a ligature of the 
umbilical cord, or from laceration or other injury, is so well known, and 
its cause so apparent, that it need only be alluded to in this connection. 
Bouchut details a case in which death occurred even before birth, from this 
form of haemorrhage. The child was attached to the placenta by a very 
short cord, which prevented delivery till it parted by the traction of the 
forceps ; but the bleeding from the umbilical vessels was so profuse, that 
the child was pallid and lifeless when born. 

There is another form of umbilical haemorrhage, cases of which have 
been from time to time observed for more than a century (one of the first 
on record was reported in the Gentleman^ s Magazine, April, 1752, by Mr. 
Watts, a physician in Kent, England), but little was done to elucidate its 
nature till three American physicians made it the subject of careful study, 
and the monographs which they have published upon it are the best which 



UMBILICAL HiEMORRHAGE. 69 

the literature of the profession aiforcls. Dr. Francis Minot read his paper, 
containing the statistics of 46 cases, before the Boston Society for Medical 
Improvement, in April, 1852. Prof Stephen Smith j)repared his paper, 
containing the statistics of 79 cases, for the New York Statistical Society, 
in 1855. It was published in the New York Journal of Medicine for that 
year. Dr. J. Foster Jenkins presented his monograph as a report to the 
United States Medical Association in 1858, and it was published in the 
Transactions of the Association for that year. This paper is very valuable 
on account of its statistics, as the writer succeeded in collecting the records 
of 178 cases, from medical journals, and gentlemen of the Association. 
These three papers contain nearly all that is known in reference to this 
disease. 

Sex — Age. — Females are less liable than males to this haemorrhage. 
In Jenkins's cases, 341- per cent, were females, 65f males. The following 
table gives the age at which the hsemorrhage commenced in 99 cases : 

Age. Nos. 

Under 1 day, 5 

Under 2 days, .7 

Under 3 " 6 

Under 4 " 3 

5 to 7 " (inclusive), . . . . , . .32 

8 " 10 " " 25 

11 " 15 " " 16 

16 " 21 " " 4 

56 " 1 

99 

Ordinarily the hsemorrhage commenced very soon after detachment of 
the cord, but in not a few the cord was still adherent. 

Causes. — The common proximate cause is feeble coagulability of the 
blood. In the normal state, when the cord is ligated, the fibrin of the 
blood, which now ceases to flow in the umbilical vessels, forms coagula so 
firm that, by the time the cord is detached, hsemorrhage is impossible. 
But in the majority of those affected with this disease, the clots are so soft 
and loose that they do not present any effectual barrier to the pressure of 
blood, which therefore oozes through them or presses them away. This lack 
of coagulability is easily demonstrated, for if a little blood, as it escapes, 
is caught in a vessel, it will be found to remain liquid a long time. This 
dyscrasia, or morbid state of the blood, which we therefore recognize as a 
chief cause of the haemorrhage, does not have the same origin in all eases. 
It is sometimes due to inherited syphilis. The infant affected with it may 
be plump, and appear well at birth, but in most instances, when the haemor- 
rhage is to occur, it is puny and cachectic, exhibiting also local manifesta- 
tions of the disease with which it is affected. Thus, in a case in my practice, 
the infant, puny, and apparently born before term, was observed to have 



70 UMBILICAL HAEMORRHAGE. 

several blebs of pemphigus on the first day, from some of which blood 
soon began to ooze, but the fatal umbilical haemorrhage did not commence 
till after two weeks. 

In about one-fifth of the cases ecchymoses or petechiie have been ob- 
served upon various parts of the surface, aflbrding additional proof of the 
general blood disease. 

Jaundice is another cause of impoverishment of the blood in the new- 
born, and therefore of umbilical hieraorrhage. The writers who have col- 
lected records of the haemorrhage, all remark the frequent occurrence of 
the icteric hue, both before and during the bleeding. It is not improbable 
that, in certain instances, the jaundice is hsematogenous, arising from de- 
struction of the red corpuscles and liberation of the hsematin, a not 
unusual result of a profound dyscrasia, whether syphilitic or originating 
in some other cause. But in other, and probably most instances, the jaun- 
dice proceeds from the liver, and is the cause of the change in the blood. 
Thus, in five of Jenkins's cases, there was occlusion of the hepatic or 
common bile-ducts, and jaundice, from the presence of biliary acids in the 
blood, causes diminution in the amount of fibrin and red corpuscles. In 
the ordinary form of icterus neonatorum, the- cause of which is found in 
the relative fulness of the capillaries and minute bile-ducts in the acini of 
the liver, the coagulability of the blood must evidently be impaired in pro- 
portion to the degree and duration of the jaundice. 

Poor health of the mother, and impoverishment of her blood during 
gestation, whether from chronic disease, as tuberculosis, or anti-hygienic 
conditions, also cause impoverishment and diminished coagulability of the 
blood of the child, and is therefore a cause of the haemorrhage. The ex- 
cessive use of diluent drinks or alkalies by the mother is believed by some 
to have a similar effect. 

In certain cases the haemorrhage is due to an inherited hsemorrhagic 
diathesis. In nine of Jenkins's cases the mothers were subject to monor- 
rhagia, and liable to bleed freely after parturition, and from injuries; and 
seventeen other mothers had each lost more than one infiint from umbil- 
ical haemorrhage. Probably in those cases in which the haemorrhage com- 
menced before detachment of the cord, and external to its point of inser- 
tion, the haemorrhagic diathesis is the main cause of the flow. 

Although the cause of umbilical haemorrhage in the majority of cases is 
the vitiated state of the blood itself, high authorities, among others Sir 
James Y. Simpson, have met cases in which the haemorrhage was referable 
to the state of the vessels. In order that the vessels be effectually closed 
by the fibrinous coagula, their walls should have their normal contractil- 
ity, but this is in great part lost, by inflammation (arteritis or phlebitis) 
which sometimes occurs in these vessels, as we have already seen. Inflam- 
mation, whether of artery or vein, causes thickening and infiltration of its 
parietes, loss of tone on the part of the fibres of which they are composed. 



UMBILICAL H^MOERHAGE. 71 

and therefore a patulous state of the vessel. Moreover, the inflammation 
is apt to be suppurative, and the presence of pus in the vessel obviously 
hinders the formation of a firm and effective coagulum. 

Symptoms. — Ordinarily umbilical hseraorrhage occurs without any pre- 
monition, but sometimes it is preceded by jaundice. Jenkins ascertained 
that jaundice was a prodromic symptom in 41 out of 178 cases, and with 
the icteric hue, constipation, clay-colored stools, deeply tinged urine, etc., 
were sometimes recorded. Rarely colicky pains and vomiting preceded 
the haemorrhage. The blood may be arterial or venous, or both. It oozes 
slowly or rapidly, rarely escaping in a jet, even when there is reason to 
believe that it is arterial. 

Peognosis. — This is unfavorable. Statistics show that five in every six 
perish. The prognosis is most unfavorable when jaundice or pui'pura is 
present. Those are most likely to recover who have a healthy parentage, 
no obvious dyscrasia, and in whom the haemorrhage occurs late, and is not 
profuse. The average duration of the hsemorrhage in 82 fatal cases in 
Jenkins's collection was three and a half days, the minimum being only 
three hours. After the arrest of the hsemorrhage, death may occur from 
exhaustion or the dyscrasia. 

Treatment. — The treatment should be both constitutional and local. 
It is important, so far as time will permit, to ti-eat the dyscrasia, and as the 
stools are apt to be constipated, a laxative is ordinarily indicated. A 
laxative is not only useful for its effect on the hepatic circulation, but as 
a derivative. Both Smith and Jenkins recommend calomel for this pur- 
pose. The modes of treating the bleeding part have been various. Those 
most deserving of mention are the following: Injecting a styptic into the 
open vessels, applying a styptic by compress or sponge to the navel, cover- 
ing the navel with dry or wet plaster of Paris, constant pressure with the 
finger, which is tedious, but which maternal solicitude willingly provides, 
and lastly, the use of needles with ligature. All of these methods have 
been more or less successful in arresting the haemorrhage, but the last is 
most effectual, though painful. Two needles should be passed through the 
umbilicus at right angles, and a waxed thread wound around each in the 
form of the figure 8. In four or five days the needles should be removed, 
and a poultice or simple dressing applied. 



72 DIAGNOSIS OF INFANTILE DISEASES. 



CHAPTEE XIII. 

DIAGNOSIS OF INFANTILE DISEASES. 

General Observations. 

Diseases in early life differ in important particulars from those occur- 
ring in maturity. Some which are common in the former age are unknown 
or are rare in the lattei-, and those which occur equally at all ages often 
present peculiar symptoms and a peculiar clinical history in the young. 
Therefore physicians who are skilful in treating adults, may be unskilful 
in treating children. Excellence as a physician of children can only be 
achieved by special and continued study of their ailments. 

Again, as regards the diseases of infancy, in which period there is a 
great amount of sickness and a large mortality, diagnosis must evidently 
be made from the objective symptoms ; from examining the features, atti- 
tude, utterances, the pulse, respiration, etc., and inspecting the surfaces, so 
far as they are accessible to view, and the eliminative products. We lack 
for this age the important information which speech affords. Some general 
remarks, therefore, in reference to the appearances and functions of' the 
system in early life, and the changes which they undergo in various path- 
ological states, seem requisite, in order to a clearer appreciation of the 
symptoms, and more ready diagnosis of individual diseases. 

Features, External Appearance of Head, Trunk, and Limbs in Disease. 

In the new-boi-n, as soon as respiration and the new circulation are es- 
tablished, the cutaneous capillaries become distended with blood, and the 
skin presents a congested appearance. By the close of the first week this 
external hypertemia begins to abate, and is soon replaced by the normal 
capillary circulation. 

Icterus is common in the first and second week. Bouchut attributes it 
to mild hepatitis. A much more plausible view of its causation, and prob- 
ably the correct one, is that of Frerichs, who attributes it to the effect on 
the hepatic circulation of ligation of the umbilical cord. By ligation the 
current of blood through the umbilical vein to the liver ceases, the amount 
of blood in the hepatic capillaries, which connect Avith the branches of the 
vein, diminishes, and then, according to Frerichs, diversion occurs of a 
part of the bile from the hepatic cells into the capillaries, while the rest 
flows in the normal manner in the bile-ducts. The degree of jaundice is 



FEATURES, EXTERNAL APPEARANCE OF HEAD, ETC. 73 

proportionate to the amount of bile which enters the circulation. Icterus 
neonatorum is not a disease of importance. It subsides without medicine 
in the course of one or two weeks, when the circulation through the liver 
becomes equalized and regular. 

The surface, or portions of the surface, of the new-born often present 
for a few hours a livid color, due to the mode of delivery. Protracted 
lividity occurs from atelectasis or malformation in the heart or great ves- 
sels; lividity induced by exertion or excitement Avhile the respiration is 
normal, indicates malformation of the heart or vessels; temporary lividity 
sometimes occurs in severe acute diseases, especially those of the respira- 
tory organs; lividity, whether temporary or permanent, is a sign of imper- 
fect decarbouizatiou of the blood. 

The cheeks of children are congested in febrile and inflammatory dis- 
eases, except in a cachectic or prostrated state of system. Transient circum- 
scribed congestion of the face, ears, or forehead constitutes a reliable sign 
of cerebral disease. Strabismus occui-ring in connection with febrile re- 
action, oscillation of iris, inequality of pupils, and drooping of upper eye- 
lids, also denote cerebral disease. The pupils are contracted during sleep; 
evenly dilated in death. 

Dilatation of the alse nasi during inspiration, with contraction of the eye- 
brows and a countenance indicative of suffering, attends severe inflamma- 
tion of the respiratory organs. Absence of tears during the act of cry- 
ing shows a severe and probably fatal form of disease in infants over the 
age of four months. 

Rapid wasting of the features, causing deep suborbital depressions, 
prominence and pointedness of the cheek-bones and chin, and hollowness 
of the cheeks, is a sign of a severe diarrhoeal affection ; the most striking 
examples of this sudden collapse of features are afforded by patients 
aff*ected with cholera infantum. In severe cases of this disease the physi- 
ognomy, from a state of fulness and health, presents in a few hours such 
a wasted and senile appearance that the friends with difficulty recognize 
the features with which they are familiar. Muscular tonicity is also greatly 
impaired in this disease, that of the orbicular muscles of the lips and eye- 
lids to such an extent that the mouth is open and eyeballs exposed during 
sleep. Great emaciation occurring gradually, is a symptom of subacute or 
chronic disease of a grave character, often of tuberculosis or chronic 
entero-colitis. 

Strabismus sometimes occurs in children who have no serious disease. 
It is then due to simple paralysis of one or more of the motor muscles of 
the eye. But when supervening upon other symptoms of a neuropathic 
character, it is a grave symptom, indicating organic disease of the enceph- 
alon, as eff'usion, meningitis, etc. A permanently downward direction 
of the axes of the eyes, with smallness of the face and great expansion of 
the cranium, is a sign of congenital hydrocephalus. The scalp in this dis- 



74 DIAGNOSIS OF INFANTILE DISEASES. 

ease is tense, bald, or sparingly covered with hair, the fontauelles and 
sutures open and enlarged, and the cranial bones yielding to pressure. 
Great expansion of the cranium above the ears, while the frontal portion 
is not enlarged, or but slightly, denotes hypertrophy of the brain. 

The appearance of the general cutaneous surface possesses much greater 
diagnostic value in the diseases of infancy and childhood than in those of 
adult life. The eruptive fevers so common in the young, and comparativly 
rare in the adult, reveal themselves to us in great part by the changes 
which they cause in the appearance of the integument. The peculiar 
color of the skin in constitutional syphilis, hereafter to be described, and 
which is more marked in infancy and early childhood than at any other 
age, is a diagnostic sign of great value in obscure cases. In the infant the 
cold stage of intermittent fever is manifested, not by muscular tremors, 
but by lividity, pallor, and the goose-skin appearance of the surface. 

Bulbous enlargement of the fingers and incurvation of the nails are 
signs of cyanosis, and therefore of malformation at the centre of the cir- 
culatory apparatus, or of tuberculosis, or ^chronic pulmonary disease 
attended by malnutrition. Enlargement of the spongy portions of bones, 
causing prominences, softness, and bending of the bones, and consequent 
deformity of the limbs, patency of the fontanelles, a large and squai'e 
shape of the head from calcareous deposit external to the cranium, are 
among the signs of rachitis. 

In early infiincy the glands of the skin and mucous surfaces, or which 
connect by their orifices with these surfaces, are slightly developed. There- 
fore sensible perspiration and lachrymation are rare under the age of three 
months. A thick Meibomian secretion of a puriform appearance collect- 
ing between the eyelids, is an unfavorable prognostic sign; it indicates a 
state of great depression ; it is observed most frequently in cerebral and 
intestinal affections a little before death. Passive congestion of the vessels 
of the conjunctiva sometimes occurs under the same circumstances, due to 
feebleness of the heart's action, and imperfect capillary circulation. It 
indicates the near approach of death. 

Attitude — Movements — The Voice. 

A sharp, piercing cry, head firmly retracted, flexure of the limbs with 
a degree of rigidity, adduction of the great toe, clonic or tonic spasm of 
the muscles, irregular movements of one or more limbs, with consciousness 
impaired, or with mental hallucinations, are symptoms of grave disease of 
the cerebrospinal system. Irregular muscular movements partly con- 
trolled by the will, and occurring daring full consciousness, are symptoms 
of chorea, a disease nearly always ending favorably in children, though in- 
curable in the adult. Contraction of the eyebrows, turning of the eyes and 
face from light, avoidance of noises, as if painful, ai"e signs of headache. 



I 



RESPIRATOEY SYSTEM. 75 

Frequent carrying of the hand to the ear, and pressing with the ear against 
the breast of the mother or nurse, are symptoms of otalgia. Frequent 
carrying of the fingers to the mouth, in connection with fretfulness or 
other symptoms of suffering, indicates stomatitis, gingivitis whether from 
difficult dentition or other causes, painful pharyngitis, or some obstructive 
disease of the larynx. Frequent rubbing or pressing the nose may be due 
to intestinal worms or intestinal irritation from other causes. It may be 
due to coryza or headache. Frequent forcible rubbing or stinking the nose 
should lead to a careful examination and perhaps guarded prognosis. It 
often indicates grave cerebral disease, and may be a precursor of convul- 
sions. 

In sevei'e obstructive disease of the larynx, the child is restless, moving 
from side to side. In most inflammations of the respiratory organs, a semi- 
erect position gives most relief. The voice in severe laryngitis is often 
hoarse or indistinct, and usually so in the pseudo-membranous form ; in 
pleuritis or pneumonitis it is restrained and abrupt, since the movements 
of the walls of the chest give pain. 

The voice in severe diseases of the abdominal organs is feeble and plain- 
tive. It is sometimes short and restrained in acute dyspepsia, in peritonitis, 
and in cases of great abdominal distension. The horizontal position gives 
most relief in abdominal diseases. In case of abdominal pain the patient 
often presses his hand upon the abdomen and flexes his thigh over it. Per- 
fect quietude, with features sunken, and unchanged by smile or crying, is 
a symptom of severe and exhausting diarrhoeal affections. 

Respiratory System. 

The respiration of the infant under the age of six months is very irregular, 
and it is more irregular the nearer the time to birth. If the new-born in- 
fant is closely observed, it will be seen to sigh often ; it breathes pretty uni- 
formly and regularly for a moment, and then, without appreciable cause, 
the respiration is intermitted ; it holds its breath when it smiles or moves 
its head, or even its limbs ; it is very subject to hiccup; this is more com- 
mon the first week of life than at any other age. So much is the breath- 
ing of the young infant disturbed by these causes, that the number of 
respirations ordinarily varies in consecutive minutes. In order, therefore, 
to determine with accuracy the frequency of the normal respiration for this 
time of life, it is necessary to take the average of several observations. 

At birth, while the function of the heart has for months been regularly 
performed, the lungs are still quiescent. The one organ has been active 
during the greater part of foetal development, the other is yet untried. 
Hereafter, in the new order of things, so intimate is the relation between the 
heart and lungs, that the proper performance of the function of the one is 
essential to that of the other. Therefore the commencement of respiration 



76 



DIAGNOSIS OF INFANTILE DISEASES. 



and the return of circulation, which is modified and temporarily arrested 
at birth, are nearly simultaneous. Respiration commences in the first half- 
minute of independent existence; often, indeed, attempts to inspire occur 
before the delivery is completed. The exceptions to this early establish- 
ment of respiration are, after tedious or unnatural births. The return of 
circulation is a moment later. 

Respiration in Health. — As the air-cells at birth are closed, the 
establishment of respiration is difficult. The air at first penetrates a few 
pulmonary cells, but gradually more and more are inflated through the 
forcible inspirations which the crying of the infant produces, till after a 
variable time respiration becomes easy and complete. If the cry is feeble, 
and especially if with this feebleness there is considerable congestion of the 
brain, the result of tedious birth, the full establishment of respiration is in 
a corresponding degree gradual and slow. 

The frequency oi the respiration in health should be ascertained, in 
order to determine whether, in a given case, it is abnormally accelerated. 
The following table embodies the result of observations which I have made, 
in order to determine the normal frequency of respiration in the first year 
of life. 

Normal Injantile Respiration (jiumher per minute). 





Age. 




First 
half 
hour. 


From first 

half hour to 

close of first 

week. 


From close 
of first week 

to close of 
first month. 


From closeof 

first month 

to close of 

third. 


Close of 

third to close 

of sixth 

month. 


Close of 

sixth month 

to close of 

first year. 




^ 
«) 


ft 


1 

<5 


1 


ci5 

1 

< 


ft 

1 


t 
< 


i 

1 


1 

< 


ft 


Number of observatious... 

Extreme number of res- 
pirations per minute 

Mean number of respira- 


29 
25-104 

4S.5 


28 

32-G4 

52 


14 

40-64 

52 


13 

40-96 
59 


13 

28-60 
45 


16 

32-68 

51 


10 

28-52 


25 

36-88 
54 


7 

24-40 

33 


19 

28-64 

41 


6 

24-36 
29 







As the child advances from the age of one year, the number of respira- 
tions per minute gradually diminishes; but through the whole period of 
childhood it remains greater than in the adult. At the age of five years, 
when the child is quiet, but awake, it is about 27 ; at the age often years, 
about 22. 



Respiration in Disease. — In cerebral diseases the respii-ation is apt to 
be slow, and if somnolence occur, intermittent, and accompanied by sigh- 



CIRCULATORY SYSTEM. 77 

iug. In youug infants, in the drowsiness which supervenes when the blood 
is imperfectly decarbonized, during severe attacks of capillary bronchitis, 
or broncho-pneumonia, respiration is apt to be intermittent. 

In inflammatory diseases of the larynx and trachea, respiration is but 
slightly accelerated, and, if there is no obstruction, its rhythm is normal; 
if there is obstructive disease, its rhythm is altered ; the inspiratory act is 
lengthened. In bronchitis, respiration is accelerated in proportion to the 
degree of extension downward of the inflammation. It is in no disease 
more accelerated than in severe capillary bronchitis. 

In pleuritis and pneumonitis, the respiration is accelerated in proportion 
to the extent and acuteness of the inflammation. Inspiration ending ab- 
ruptly, and succeeded by an expiratory moan, is a symptom of both pleu- 
ritis and pneumonitis in their acute stages. In certain cases of irritative 
or inflammatory disease of the abdominal organs, I'espiration presents a 
similar character; it is modified in this manner in consequence of the pain 
experienced in movements of the diaphragm. Ordinarily, however, in 
abdominal diseases, respiration is nearly natural. 

The cough is an important diagnostic symptom. It is loud and sonorous 
in spasmodic croup, hoarse or harsh in true croup, clear and distinct in 
bronchitis, suppressed and painful in the early stages of pneumonitis and 
pleuritis, convulsive and with more inspirations than expirations in per- 
tussis. A cough is one of the first and most constant symptoms of measles; 
it is due to coexisting bronchitis. Typhoid and remittent fevers, difficult 
dentition, intestinal worms, irritating ingesta, and severe burns, sometimes 
give rise to a cough, which is nearly dry and painless. Occurring in such 
diseases, it is sometimes dependent on more or less bronchitis, to which the 
primary disease has given rise. 



Circulatory System. 

In all ages and countries the pulse has been considered an important 
symptom both in diagnosis and prognosis. It aids the practitioner in de- 
termining, approximatively, not only the character, but gravity of diseases. 
It is soniL'what remarkable, from the importance which is attached to the 
pulse in medical practice, that its natural frequency and its character in 
infancy are not more accurately known. It is true that eminent observers, 
as Trousseau and Valleix, have published statistics relating to the infantile 
pulse in health, but these statistics disagree, and therefore do not afford a 
reliable standard with which to compare the pulse in disease. Moreovei', 
some published statistics of the pulse possess but little value, from the 
small number of observations; some from the fact that records of the in- 
fantile pulse are grouped with those of older children ; and others because 
the state of the infant, as regards its activity or emotions, is not mentioned. 



78 



DIAGNOSIS OF INFANTILE DISEASES. 



Pulse in Health. — It is not ea.sy to collect statistics of the healthy- 
pulse for the period of infancy, which are entirely free from error, since 
there are often slight derangements of the system in the infant, which are 
not manifested by any marked symptoms, but which produce acceleration 
of the pulse. In collecting the following statistics, it was my endeavor to 
avoid sources of error so far as possible. 

In ordinary cases the movements of the heart begin about one-eighth of 
a minute after birth. They are at first slow, the ventricular contractions 
not numbering more than eight or ten by the close of the first quarter 
minute. In the second quarter the cries are vigorous, and the pulse now 
is rapidly accelerated, rising commonly above 120, and sometimes above 
160 beats per minute. In fifty -seven observations of the pulse in healthy 
infants during the first half hour of life, after the first quarter of a min- 
ute, I found that the extremes, with one exception, were 104 and 164 — 
average, 139. 

Table of Infantile Pulse in Health. 





Age. 




First 


iveek. 


From close of 

first week to 

close of first 

montli. 


From close of 
first month to 
close of third. 


From close of 
third month to 
close of sixth. 


From close of 

sixth month to 

close of first 

year. 




Awake. 
Quiet ; 
moving 
slightly; 
nursing 


d 
% 

< 


Awake. 
Quiet; 
moving 
slightly; 
nursiug 


1 


Awake. 
Quiet; 

sTighuf: 
nursing 


1 
< 


Awake. 
Quiet ; 
moving 
slightlv; 
nursing 


% 
< 


Awake. 
Quiet; 
moving 
slightly; 
nursing 


i 

1 


No. ofobser-\ 
vation j 


22 


16 


10 


10 


15 


17 


25 


6 


20 


3 


Extremes 


104-152 


108-140 


124-160 


104-144 


112-148 


104-132 


112-146 


104-116 


112-144 




Mean 


126 


122 


139 


118 


132 


118 


129 


108 


127 


109 



" M. Ledeberder," says Bouchut, " could only count the pulse in the first 
minute of life in six children, and he has observed from 72 to 94 pulsa- 
tions." Valleix estimates the pulse, between the ages of two and twenty- 
one days, at 87. Trouss§au states that the pulse, in the first week of life, 
varies from 78 to 150; and Dr. Gorham's observations are somewhat simi- 
lar to Trousseau's. My observations, as seen from the above table, do not 
correspond with the as.sertions of Ledeberder and Valleix. Indeed, if 
there were no conflicting testimony, there would still be a strong presump- 
tion that these authors are in error, for we would not suppose that the pulse 
of the infant, in whom there is greater functional activity, both muscular 
and visceral, would fall so much below that of the foetus. It is probable, 
from the expression "could only count the pulse .... in six children," 
that Ledeberder and perhaps Valleix counted the pulse at the wrist, which, 
with exceptional cases, is very difficult and often impossible in the first 



CIRCULATORY SYSTEM. 



79 



week of life, and that they missed some of the beats, or, not unlikely, 
sometimes counted their own pulse. Immediately after birth there is so 
little force of the ventricular systole, and the extreme arteries, therefore, 
of the system pulsate so feebly, that neither in the limbs nor at the an- 
terior fontanelle can the frequency of the pulse be readily ascertained. It 
can be readily and accurately ascertained only by auscultation, or by 
placing the hand on the precordial region, or directly after birth by the 
pulsations in the umbilical cord. 

The average pulse of the healthy infant in the first and second months 
is, according to Trousseau, 137 per minute, 128 from the third to the sixth 
month, and 120 from the sixth to the twelfth month. It is seen that his ob- 
servations agree closely with mine, as regards infants who are quiet but 
awake. One point of interest, established by the above statistics, is the 
great diminution in the frequency of the pulse in sleep. 

Pulse during or after Active Movements or Great Mental Excitement. 







Close of first 


Close of first 


Close of third 


Close of sixth 




First week. 


week to close of 


to close of third 


to close of sixth 


month to close 






first month. 


month. 


month. 


of first year. 




140 


162 


176 


132 


132 




160 


156 


152 


148 


144 




140 


140 


158 


148 


152 




152 


152 


144 


144 


152 








152 


156 


1!)8 








180 


156 


160 


Extremes, . . . 


140-160 


146-162 


144-180 


132-156 


132-198 


Mean, 


148 


152 


160 


147 


156 



It is seen, by the above table, that by active exercise or great mental 
excitement the pulse may become as rapid as in grave diseases. There is 
greater acceleration of pulse from the emotions and from exercise in feeble 
than in robust children. Obviously, in order to determine to what extent 
the pulse is accelerated in disease, it is necessary that it should be counted 
during a state of quietude. As the age increases, it is less and less in- 
fluenced by the emotions and physical exertion; still, during the whole 
period of childhood, such influences do have more or less effect on its fre- 
quency. 



Pulse in Disease. — Febrile and inflaniiiuitory discuses produce greater 
acceleration of pulse in early life than in maturity. Diseases, or derange- 
ments of system, particularly those of the digestive organs, which do not 



80 DIAGNOSIS OF INFANTILE DISEASES. 

materially affect the pulse in the adult, often cause acceleration of it in 
children. The febrile pulse of early life usually has exacerbations in its 
frequency. These commonly occur in the latter part of the day. Distinct 
and more or less regular febrile exacerbations and remissions are common 
in several diseases of early life, some of which are serious, while others 
involve little danger. Among these diseases may be mentioned difficult 
dentition, intestinal worms, incipient meningitis, and constipation. An 
intermittent and irregular pulse is common in fully developed meningitis 
and certain other severe organic diseases of the encephalon. It may be 
due also to disease of the heart, and it also occurs in some children from 
temporary disturbance of the digestive function. The pulse is slow in 
compression of the brain, and also in sclerema of the new-born. 

Animal Heat. 

The internal temperature of the body in a state of health is uniform. 
In 33 infants under the age of seven days, M. Roger found the average 
temperature 98.6° Fahr., while in 25 from four months to fourteen years 
old it was 99°. The external temperature alone varies in a state of health, 
according to the temperature of the atmosphere. 

Elevation of temperature above the normal standard is a sign of in- 
flammatory and febrile affections. The increase of heat varies according 
to the character of the disease and its type. In favorable cases of inflam- 
mation and in simple fevers it is not ordinarily more than two or three de- 
grees. The greater the severity and malignancy of inflammatory and 
febrile diseases, the greater the elevation. An elevation of more than six 
degrees indicates a form of disease which is likely to prove fatal. It is rare 
that the temperature, even in fatal cases, rises above 107°. In measles 
the temperature in the eruptive stage is from 101° to 103° ; in scarlatina 
from 102° to 104°, if no complication exist. 

Reduction of the internal temperature is an unfavorable prognostic sign ; 
it is observed, a few hours before death, in infants who are greatly reduced 
by certain chronic diseases, as eutero-colitis. In these cases the tongue and 
even sometimes the breath communicate to the finger or hand a sensation 
of coldness. 

The importance of thermometric observations, as an aid to the diagnosis 
of children's diseases, is within a few years more fully recognized by the 
profession. Two diseases which, in their commencement, present very 
similar symptoms, often vary as regards the temperature. Thus, men- 
ingitis presenting in its first stages symptoms very similar to those of 
typhoid fever, has a lower temperature till an advanced period, when the 
amount of heat increases. 



DIGESTIVE SYSTEM. 81 



Digestive System. 



Inspection of the buccal aud faucial surfaces discloses some of the most 
frequent local diseases of infancy, as the various forms of stomatitis, and 
others which, though not frequent, involve great danger, as gangrene of 
the mouth, diphtheria, and retro-pharyngeal abscess. Inspection of the 
tongue aids in determining in many cases whether the disease is pursuing a 
favorable course, or has become asthenic, aud is exhausting the vital 
powers. 

Febrile movements, even when slight, give rise to coating of the tongue, 
and intumescence and distinctness of its follicles. The eruptive fevers are 
attended by changes upon the buccal and faucial surfaces which possess 
diagnostic and prognostic value. Hypersemia of these surfaces appears 
early in rubeola and scarlatina, prior to those phenomena which are justly 
regarded as pathognomonic. It is therefore often an important sign in 
the initial period of those diseases when the diagnosis is obscure. The ap- 
pearance of the fauces in diphtheria and croup, indicating not only the 
nature of the disease, but its gravity, need only be referred to in this con- 
nection. 

Inspection of the buccal and faucial surfaces sometimes enables us to 
form a probable opinion in reference to the nature of diseases which are 
seated in other parts. In the infant protracted stomatitis is a common 
accompaniment of chronic diarrhoea, and it indicates its inflammatory 
nature. 

Vomiting is more frequent in infancy than in childhood, and in either 
period than in adult life. It is common in cerebral affections, and is one 
of the first symptoms of scarlet fever, and it is not uncommon, though less 
frequent, in the commencement of the other essential fevers and of acute 
inflammations. It is a symptom of indigestion, entero-colitis, cholera in- 
fantum, and intussusception ; it is common, also, after the paroxysmal 
cough of pertussis, and not infrequent in the bronchial inflammations of 
young infants ; in both wdiich diseases it is excited by the muco-purulent 
matter upon the faucial surface. 

Intestinal gas is in part secreted or exhaled from the mucous membrane, 
as the experiments of Hunter and others have shown, and it is in part the 
product of chemical changes in the food. A certain amount of gas in the 
intestines is normal ; it subserves a useful purpose. An abnormal amount 
of it is common in various diseases, as indigestion, chronic entero-colitis, 
peritonitis, typhoid fever. It is a frequent cause of gastralgia and enter- 
algia in the infant. In scrofulous or feeble infants, with impaired muscular 
tonicity and faulty digestion, the abdomen is often habitually more or less 
distended with gas, which does not, under such circumstances, give rise to 

6 



82 



DIAGNOSIS OF INFANTILE DISEASES. 



pain or other local symptoms; it has significance as showing the general 
condition of the child. 

In the rachitic, whose thorax is compressed and liver often enlarged, 
while the vertebral column is shortened, the abdomen is commonly pro- 
tuberant. In feeble children, not decidedly 
rachitic, whose lungs are seldom fully iu- 
'^ flated, and whose chests are consequently de- 

pressed, the abdomen is also prominent. The 
accompanying woodcut represents one of these 
cases, presented for treatment at the outdoor 
department at Bellevue. 

In feeble children who have suffered from 
repeated and protracted attacks of bronchitis, 
and whose chest-walls are consequently de- 
pressed, a similar abdominal prominence oc- 
curs. 

Retraction of the abdominal walls is com- 
mon in meningitis, and in many exhausting 
diseases. Tenesmus is a symptom of intus- 
susception in the infant, and of colitis in chil- 
dren. 

Much light is thrown on the character of 
intestinal diseases by the appearance of the 
stools. Muco-sanguineous stools accompanied 
by fever, are a sign of colitis. Stools containing unmixed blood, and not 
accompanied by fever, may result from a rectal polypus and from purpura 
haemorrhagica. Scanty evacuations of blood, with obstinate constipation, 
are a symptom of intussusception in infants. 

The alvine discharges of infants often present a green color; sometimes 
they have the normal yellow hue when passed from the bowels, but be- 
come green on exposure to the air, or from reaction of the urine. By the 
microscope the green coloring matter is seen to occur in small irregular 
masses. This green substance has been supposed to be bile. I am con- 
vinced that as it occurs in the stools of the infant, it is commonly pro- 
duced by the action of the intestinal secretions on the contents of the in- 
testines; perhaps the action is upon the bile which is mingled with the 
contents, for I have often noticed that the contents in and above the 
jejunum were yellow, while in and below the ileum their color was green. 
The green hue may occur from very different causes. It may be due to 
over-feeding, to the action of cold, to irritating ingesta, to inflammation, 
etc.; it may be transient, subsiding within a day or two, or it may continue 
several days. All infants, at times, have green evacuations, even when 
they appear in good health. 




NERVOUS SYSTEM. 83 

In a large proportion of the cases of diarrhoeal maladies occurring during 
infancy the stools give an acid reaction with litmus-paper. This acid, if in 
considerable quantity, is irritating, increasing the peristaltic movements of 
the intestines, and the functional activity of the intestinal follicles, caus- 
ing erythema of the skin around the anus, and reacting upon and intensi- 
fying the intestinal disease. Hence the indication for the use of antacids 
in the diarrhceal affections of infancy. 

The presence of intestinal worms and the species may be ascertained by 
microscopic examination of the stools of the child Avho is affected with 
these entozoa. The stools contain ova, which differ in size and shape 
according to the species of worm. 

Nervous System. 

Pain. — This symptom affords important aid to the physician in deter- 
mining the seat and nature of the diseases of children. Pain in the head 
may occur in them from coryza involving the frontal sinuses, or from febrile 
movement in the commencement of an essential fever, or of inflammation 
of one of the organs of the trunk. Produced by such a cause, it abates in 
two or three days. If it is protracted, whether constant or intermittent, 
it is almost never neuralgic, as it so often is in the adult, but it is due to 
organic disease of the brain or meninges. Complaint, thei^efore, of head- 
ache in a child, without any apparent general cause, or local cause external 
to the cranium, should awaken solicitude, and, if it is protracted, the phy- 
sician should examine carefully in reference to the presence of a cerebral 
or meningeal disease. 

Grave thoracic or abdominal inflammations in the adult are almost 
always attended by a corresponding amount of j)ain and tenderness ; but 
in children these symptoms are often absent, or, when present, are often 
not commensurate with the amount of disease. Thus, enterocolitis of nurs- 
ing infants is, in a large proportion of instances, almost free from these 
symptoms, and the same may be said of many cases of pneumonitis in 
young children, namely, those cases produced by extension of inflamma- 
tion from the bronchial tubes and from hypostasis. 

Pain in the chest or abdomen, occasional or constant, continuing for 
weeks or months, unattended by symptoms of thoracic or abdominal dis- 
ease, indicates caries of the vertebrae. Its most common seat is the epi- 
gastric, umbilical, or hypochondriac region. It is a neuralgia due to irri- 
tation of the sensitive root of one or more of the spinal nerves. It is a 
very important symptom to the diagnostician, showing the nature of the 
disease, which in its iucipiency is so obscure. Pain in the leg, especially 
the inside of the knee, is of a similar character, indicating disease of the 
hip-joint. 



84 DIAGNOSIS OF INFANTILE DISEASES. 

Cliildreu with certain acute febrile and inflammatory diseases some- 
times have hyper^esthesia of portions of the surface: it is especially marked 
upon the anterior aspect of the trunk. The physician might be misled 
into the belief that the tenderness occurred over the seat of the disease and 
indicated an inflammation; but the pain of hypersesthesia can be diagnos- 
ticated from that of inflammation by the fact that it is so extensive, is less 
on firm than light pressure, and is especially observed upon the inner sur- 
face of the thighs. The symptoms pertaining to the nervous system occur- 
ring in the various diseases treated of in this book will be fully described 
in connection with those diseases, and, therefore, need not detain us in this 
connection. 



i 



PART II. 

CONSTITUTIONAL DISEASES. 



SECTION I. 

DIATHETIC DISEASES. 



CHAPTER I. 

KACHITIS. 

Rachitis, or rickets, is a disease of the general nutritive process ; but 
the structural changes which attend and characterize it are most con- 
spicuous in the bones. 

Age. — Rachitis commences in most instances between the ages of six 
months and two years. Now and then we meet cases of its earlier as well 
as later commencement, and skeletons are preserved in 
museums, which seem to show that in rare instances ^'" '^ 

rachitis is congenital. Virchow alludes to such a speci- 
men in the Wurzburg Museum, and Ritter von Ritters- 
bain describes another in the Museum of the Franz 
Joseph Hospital in Prague. In the Wood Museum of 
Bellevue Hospital is a similar skeleton presented by 
myself, and represented in the accompanying woodcut. 
The infant in this case died a few hours after birth, of 
atelectasis, apparently produced by the contracted state 
of the thoracic walls. The parents are hard-working 
English people, whose surroundings are such as are 
known to predispose to rachitis. 

Enlargement of the costo-chondral articulations, known 
as the "rachitic rosary," which is one of the earliest and 
most reliable signs of rachitis, has been observed, though 
rarely, in infants of two or three months. It should not, 
however, be regarded as a sign of rachitis unless the en- 
largement is so great that it can be readily appreciated 
by examination through the integument or by sight, for 
in young children, with the bones in the process of normal development. 




86 RACHITIS. 

these joints always have a greater diameter than that of the ribs. After 
the age of two years the number of those affected with rachitis gradually 
becomes less as we pass towards manhood. 

Published statistics relating to the commencement of rachitis have been 
derived chiefly from European hospitals. Of 521 cases observed by Ritter 
von Rittershain, 266 were under the age of twelve months, and 91 under 
six months. Of Hillier's cases, 7 were six months old or under, 27 from 
six to twelve months, 40 from twelve to twenty-four months, 40 from two 
years to four years, and 3 over the age of four years. As rachitis so often 
commences insidiously, these statistics must be considered only approxi- 
mately correct, especially as regards those cases which are supposed to 
have had an unusually late commencement. 

Is rachitis ever developed in the adult? Osteo-malacia, or mollities 
ossiura, a rare disease of adults, occurring with few exceptions in women 
after childbirth, resembles rachitis, since it is attended with softening of 
the bones from the absorption of their calcareous element. Trousseau, 
and following him, Bouchut, believe in their essential identity, regarding 
their difl^erences as due to the difference in age, and especially to the fact 
that in osteo-malacia the bone has attained its growth, whereas in rachitis 
it is still growing. Moreover, as arguments in favor of their close relation- 
ship, rachitis and osteo-malacia are found to require very similar treatment, 
and women after childbirth resemble children as regards aptitude for 
disease. 

Causes. — Rachitis, as we have stated elsewhere, is entirely distinct in its 
nature from scrofula. The scrofulous are not likely to become rachitic, 
nor the rachitic scrofulous. Proneness to low grades of inflammation or to 
hyperplasia of the lymphatic glands, which characterizes scrofula, seldom 
exists in connection with swelling of the bones or other manifestations of 
rachitis. The differences between the scrofulous and rachitic diatheses, 
which indeed seem to exclude each other, are marked. The scrofulous are 
well developed and of good height, as a rule, while the rachitic are stunted. 
Scrofula manifests itself not less frequently in childhood than in infancy, 
whereas rachitis we have seen is especially a disease of infancy. Again, as 
showing the difference between the two, scrofula is not infrequently asso- 
ciated with tuberculosis, whereas rachitis with tuberculosis is rare. 

Residence in a cold and moist climate, or in dark, damp, and ill-venti- 
lated apartments, is a cause of rachitis. Therefore it is more common in 
the north of Europe than in the warm and equable climate of southern 
Europe ; in the damp and dai'k basements and alleys of the city, than in 
dry and airy country residences. In deep valleys, shut out from the solar 
rays, rachitis is more common than among people of the same habits and 
social position living in elevated and sunlit localities. 

A common cause of rachitis is the use of insufficient or improper food. 
This has been ascertained not only from the history of rachitic children, 



RACHITIS. 87 

but from experimeuts oo animals. Diminution in tlie relative amouut of 
lime and consequent softening of the bones have been produced in various 
animals by the use of scanty food, or food deficient in nutritive properties. 
Artificial feeding of young animals at the time when nature designed that 
they should be nourished by the mother's milk has had the same result. 
(Experiments by M. Jules Guerin and others.) Rachitis is more apt to 
occur in those who are prematurely weaned than in those who nurse the 
full time. Those are most likely to become rachitic in a marked degree, 
even fatally, who at the same time have scanty and improper food, and 
reside in damp, dark, and insalubrious localities. 

An hereditary predisposition to rachitis must also be admitted, since 
infants born of rachitic parents are more likely to become rachitic than 
are those of healthy parentage. The mothers presented traces of rachitis 
in 27 out of 71 cases observed by Ritter von Rittershain. A mother in 
habitual ill health and poorly nourished, though without actual disease 
during the period of gestation, is more apt to have rachitic offspring than 
is a mother whose health is habitually good. 

It is not true, as some have stated, that all that is required to produce 
rachitis is a certain lowering of the vital powers, since all greatly enfeebled 
infants would become rachitic, whei'eas only a portion of such present the 
anatomical changes which characterize this affection. Cachexia is, how- 
ever, an important predisposing cause, and therefore the rachitic state not 
infrequently supervenes on certain exhausting diseases, as the eruptive 
fevers, pertussis, and enterocolitis. There are supposed to be two direct 
causes or factors in the production of rachitis : one a deficiency of phos- 
phates in the blood, due to the use of improper food or to faulty digestion; 
the other an excess of acids, probably mainly the lactic produced by the 
same causes, which acid or acids dissolve the phosphates in the blood, so 
that they are eliminated from the kidneys, instead of being deposited as 
alkaline lime salts in the bones. 

Anatomical Chakacters. First Stage. — M. Lebert says : " In rachitis 
the bone is diseased in all its histological elements, and the skeleton in its 
totality." It commences with proliferation of the periosteum and of the 
cartilages of the epiphyses. In the normal state the new tissue formed by 
this proliferation changes into bone by the deposits of the lime salts, that 
formed from the periosteum increasing the thickness of the bone ; that from 
the cartilages, their length; but in rachitis, as already stated, the osseous 
change does not occur. Soon the areolae, which abound in the ends of the 
long bones, in the short bones, and in the diploe of the flat bones, are ob- 
served to enlarge, and the laminse of which the compact bone is composed, 
to separate more or less from each other, foi'miug iuterlamellar spaces. 

The areolar and interlamellar spaces are filled with a gelatiuiform fluid 
of a pale reddish color. The same substance fills the medullary canals, 
and, in certain situations, more or less of it is deposited between the peri- 



88 RACHITIS. 

osteum and the external surface of the bone. The amount of subperiosteal 
deposit in a given place, depends in a measure on the tensity and degree 
of adherence of the periosteum. Thus when curvatures occur, the quan- 
tity of this substance deposited over the concave surface of the bone, where 
the periosteum is lax, is considerable, while over the convex surface, where 
it is tightly drawn, it is absent or scanty. This substance adheres quite 
firmly to the surface of bone, Avith which it is in contact, though at autop- 
sies more or less of it can be washed away by a stream of water. 

The periosteum and medullary membrane are more vascular than in 
their normal state, presenting a deep red color, and the vascularity of the 
bone itself is increased. 

Second Stage. — The second stage is that of curvatures and deformity. The 
laminse of compact portions, and the walls of the areolae, in parts that are 
cancellous, become gradually thinner and more yielding. Here and there 
loss of the animal matter in connection with the mineral occurs, pro- 
ducing new apertures and channels, in some of which bloodvessels of a new 
growth are developed. Occasionally portions of bone become detached, 
and lie as sequestra in the midst of the gelatiniform substance. The shape 
of the medullary cavity changes. The extremities of the cavity are con- 
siderably larger than its central portion. In this second stage, in typical 
cases, the relative proportion of calcareous matter being greatly reduced, 
and the new gelatiniform substance still semi-liquid, if an opportunity occur 
of examining the skeleton, the long bones can be bent, and their epiphyses, 
as well as the flat and short bones, compressed, and, in some instances, 
even crushed between the thumb and fingers. "The bones in this state can 
be cut with a knife with as much ease," says Trousseau, "as a carrot or 
other soft root." In cases in which the absorption has been considerable, if 
the bone removed from the cadaver is dried, it will be found possible to 
respire through it, so great is its porosity, and its weight is from six to 
eight times less than that of normal bone. 

If rachitis commence at an age, as it commonly does, when thediaphyses 
and epiphyses of the long bones are united by cartilage, this cartilage not 
being transformed into bone increases in extent and undergoes molecular 
changes, which have been minutely described by M. Broca. According 
to him, as we examine the cartilage beginning at the epiphysis, we find 
first a layer of cartilage which is but little changed, containing cells in 
their normal state. Nearer the diaphysis we find cartilage perforated with 
small holes, the cartilage-cells, instead of being distinct, being arranged in 
longitudinal groups, in other words, lying in longitudinal cavities, and 
flattened by mutual pressure. Near the diaphysis bands of fibrous tissue 
surround the clusters of cells. 

While the anatomical changes, described above, are occurring, the liga- 
ments which unite the bones become gradually lengthened and relaxed, 
so that there is increased mobility of the bones upon each other. 



RACHITIS. 89 

The deformities which occur in the secoud stage vary in degree in dif- 
ferent cases, according to the amount of rachitic softening and tumefaction 
of the bones, and relaxation of the ligaments on the one hand, and the 
movements of the patient on the other. If the patient is old enough to 
walk, the curvatures ordinarily occur first in the lower extremities ; but if 
too young to walk, in the upper extremities. 

Craniotahes. — Occasionally the cranial bones in rachitis become very 
much thinned and softened in places, to which the name of craniotabes 
has been applied. This thinning occurs most frequently in the occipital 
bone, and sometimes to such an extent that the dura mater and pericranium 
are nearly in contact. The soft spots are yielding when pressed upon, 
and in the cadaver they are seen to be translucent when held to the light. 
Craniotabes has been invested with considerable pathological importance, 
chiefly through the writings of Dr. Elsiisser. If the occipital bone is thin 
and yielding, the brain is liable to be unduly pressed upon at these yield- 
ing points, even by the weight of the head on the pillow. In connection 
with this, the clinical fact is significant that children with rachitis, and the 
softening of the calvarium which results from rachitis, are especially liable 
to internal convulsions. 

The changes in the shape of the head in rachitis are characteristic, and 
are so manifest as at once to attract attention. The growth of the cranium 
is not retarded like that of other parts of the system, and in some patients 
its volume is greater than the normal size. If there is considerable cranial 
development, hypertrophy or hydrocephalus commonly coexists. The ra- 
chitic skull does not always present the same shape. It may be elongated, 
but more frequently it approximates to a square shape. It is more or less 
flattened superiorly, laterally, anteriorly, and posteriorly. The sutures, 
which are late in closing, are commonly depressed, while the frontal pro- 
tuberances are unusually elevated. Elevation of the sutures in ridges has 
been observed in exceptional cases, as also flattening limited to one plane 
of the head, or greater in one than in the others, so as to destroy the sym- 
metry of the cranium. 

The accompanying wood-cut is of a child with rachitis, now in the New 
York Infant Asylum. It is 18 months old, has six teeth, a square head, 
softened and thin cranial bones, and a greatly depressed longitudinal 
suture. Within the last two months it has attacks of internal convulsions, 
in which it holds its breath and fixes its eyes, but which pass off* in i)rob- 
ably a quarter of a minute, without any noise. This child is very fretful, 
and dreads to be approached. In the same institution is another child, 
aged 15 months, without teeth, with a less marked rachitic head, and with- 
out the convulsions, but with the rachitic rosary, and a decided enlarge- 
ment of certain of the joints of the extremities. 

The deformities of the trunk and limbs occurring in the second stage 
are interesting. There is lateral depression of the thoracic walls between 



90 



RACHITIS. 



the second or third and ninth ribs, accompanied by projection of the 
sternum. The shape of the chest resembles that of the prow of a ship, to 
which Glisson likened it, or the breast of a bird. This deformity is the 
result of atmospheric pressure, occurring externally upon the thoracic 
walls during inspiration, at the time when the ribs are most softened, and 
least elastic. Depression of the first and second ribs is partially prevented 




by the support which they receive from the clavicles. The length of the 
clavicles is, however, somewhat diminished, and their curvatures increased, 
so that the shoulders approach each other. Below the ninth ribs the 
thoracic walls are expanded ; the corresponding ribs on the two sides are 
more separated from each other than in their normal state. The expan- 
sion of the base of the chest diminishes the convexity of the diaphragm, 
and causes depression of the liver and spleen. 

The abdomen in rachitis is protuberant, partly on account of the de- 
pression of the liver and spleen, partly on account of the spinal curvatures 
and shortening of the trunk, but chiefly on account of the fact that in this 
disease the intestines are distended with gas. The meteorism gives rise to 
tympanitic resonance on percussion, except occasionally over the lower part 
of the abdominal cavity, where there may be duluess from serous effusion. 

Spinal curvatures, to which allusion has been made, are common in 
rachitis. They are due to softening of the intervertebi-al cartilages, and 
the bodies of the vertebrae, and to laxity of the intervertebral ligaments. 
Their direction is commonly antero-posterior. They are distinguished from 
the deformity of caries by the absence of an angular projection. More- 
over, except in cases of long continuance, the curvature can be removed by 
placing the patient in a horizontal position, and pressing with the fingers 



RACHITIS. 



91 



on the projecting parts. The pelvic bones also undergo change of shape. 
There is expansion of the upper part of the pelvic cavity, from the pres- 
sure of the abdominal viscera, corresponding with the expansion of the 
lower part of the thorax, though not in as great degree, while the lower 
part of the pelvic cavity is contracted. 

The bend of the humerus is such in most patients that its concavity 
looks inwards and forwards, but occasionally it is directly the opposite. 





The concavity upon the forearm corresponds with the palmar surface of 
the hand. The concavity of the thigh presents towards the median line and 
a little posteriorly. The natural bend of the femur being simply increased. 
The curvatures of the tibia and fibula vary in different cases. If the in- 
fant has not walked, their concavity is commonly directed forwards and 
inwards ; but if it has walked, outwards and backwards. Occasionally, 
the direction of the bend on one side differs from that on the other. 

Third Stage. — The third stage is that of reconstruction. After a variable 
period, depending on the severity of the disease and the state of the con- 
stitution, the gelatiuiform substance becomes more consistent, and points 
of calcareous matter appear here and there within it. The deposit of lime- 
salts continues, and the newly formed bone again becomes firm and un- 
yielding. It is generally cancellous in places where the original bone was 
of this character, though the extent of the new cancellous structure is apt 
to be different from that in the normal bone. Thus not only are the 
epiphyses cancellous in the new as in the original bone, but I have seen 
the entire medullary cavity filled with cancellous structui'e. The subperi- 
osteal deposit is sometimes also transformed into cancelli. This was the 
character of the change occurring under the pericranium in one specimen 
■which I examined. Where the original bone was compact, the recon- 



92 RACHITIS. 

structed bone is usually of the same character, as, for example, in the 
shafts of the long bones. Compact portions of the reconstructed skeleton 
have been said to lack the elements of true bone ; they are osteoid, accord- 
ing to this theory, and not osseous, resulting from petrifaction of the ge- 
latiniform substance. I have, however, found the elements of true bone in 
the skeletons of two individuals who had well-marked rachitic curvatures. 
The portions examined were removed from the concavities of the long 
bones, where there had been decided bending and thickening of the shafts 
from the large amount of rachitic deposit. In both specimens the osseous 
corpuscles (lacunce) and Haversian canals were easily demonstrated ; but 
in both there had been considerable growth of the bones since the rachitic 
period, and perhaps the portions which were examined belonged to this 
subsequent growth. AVhether or not true bone is produced in the third 
stage of rachitis, that is, from the deposit of calcareous salts, which im- 
mediately succeeds the softening, certainly in the subsequent growth there 
is the formation of true bone. 

Such is a brief sketch of the changes which the skeleton undergoes in 
oi-dinary cases of rachitis. An extreme degree of softening may be reached 
in four or live months, or not till the lapse of a year or more. The third 
stage, or that of consolidation, lasts one or two years. While in the first 
and second stages there is an arrest of ossification, and a deficiency of cal- 
careous salts in the system, there is often in the third stage, as Lebert has 
stated, an exuberance of ossification, and a superabundant deposit of the 
salts of lime, so that the reconstructed bone is firmer and stronger than 
normal bone. 

Occasionally, in reduced states of system, the third stage does not occur. 
The bones remain very soft and flexible, consisting almost entirely of ani- 
mal matter. This is what has been designated rachitic consumption of 
bones. Such cases end fatally after a variable time. 

A not unfrequent accident in the second period of rachitis is fracture 
in the shafts of the long bones. If there is almost complete removal of 
the mineral substance of a bone, so that the periosteum incloses little ex- 
cept the gelatiniform deposit, and the animal matter of the old bone, the 
limb bends readily, and no fracture occurs. If there is not so complete 
absorption, the weight of the body or muscular exertion snaps rather than 
bends the weakened shaft. From the nature of the fracture, crepitation 
can rarely be produced. The callus is not generally abundant, and re- 
union of the bone is slow. Many cases of rachitic fractures are partial, 
portions of the shaft deprived of the mineral element bending, while the 
part which retains this element is fractured. 

Rachitis retards the evolution of the teeth. If the disease commence as 
early as the fifth or sixth month, no teeth commonly appear till after the 
age of twelve months; if certain teeth have appeared prior to the rachitic 
disease, an interval of several months elapses before the next are cut. 



SYMPTOMS. 93 

Teeth which are developed during the rachitic state are frail, and deficient 
in enamel. They become black and carious early, and loosen in their 
sockets. If there is no tooth at the age of twelve months, the infant is 
probably rachitic. The fontauelles and cranial sutures remain open longer 
than in healthy infants. The former may not close till the third or fourth 
year, and the latter not till the second or third year. Patency of the an- 
terior fontanelle after the age of twenty months indicates rachitis. 

Although the prominent and most interesting lesions of rachitis occur in 
the bones, anatomical changes, resulting from the disease, occasionally 
occur in the soft parts. The lymphatic glands, liver, spleen, and some 
other organs not infrequently undergo waxy degeneration, diminishing 
greatly the chances of recovery. Whether this degeneration results from 
the diathesis directly, or is due to the bone disease, the substance which is 
produced is now admitted to be the true waxy material, though for a time 
denied, as it does not always give a clear reaction with iodine. 

Eachitis influences the future growth of the skeleton. The long bones, 
though unusually thick and firm, do not attain the normal longitudinal 
development; therefore the child of ten years, who has had rachitis, is 
scarcely taller that one at six who has not been thus affected. In many 
patients the curvatures in the course of time gradually diminish, so that 
in youth and maturity the body is less misshapen than at the age of two or 
three years. It is rare, however, that the deformities entirely disappear. 

It is seen that the anatomical characters of rachitis resemble, in certain 
respects, those pathological processes which are admitted to be of an in- 
flammatory nature. The tenderness, hypersemia, proliferation, and conse- 
quent thickening of the periosteum, and the proliferation of the epiphyseal 
cartilages, are perhaps inflammatory, since they resemble more closely the 
lesions of inflammation than any other recognized pathological state. The 
soft substance, which is produced so abundantly in places underneath the 
periosteum and in the spaces of the bone, is perhaps in part an exudation, 
and in part the animal matter which is formed in the normal development 
of the bone. The immediate cause of the elimination of the lime salts 
from the kidneys, and the consequent arrest of ossification of the skeleton, 
is unknown, but it has been suggested that, as a large proportion of the 
rachitic suffer previously from indigestion and diarrhoea, with the forma- 
tion of acids in the primte vise, especially the lactic, an acid in the blood 
holds the lime in solution, and hence its elimination. But however plausi- 
ble this theory may appear, it lacks demonstration as yet. 

Symptoms. — The patient in incipient rachitis is quiet and melancholy? 
shunning caresses or attempts to amuse him, since movement of his body 
increases his suffering. He has general tenderness, due in part to the mor- 
bid state of the periosteum, and in part to hypersesthesia. The rachitic 
infant, therefore, unless very mildly affected, will evince anxiety and 
dread even at the approach of one, through fear of being touched or 



94 RACHITIS. 

moved. Trousseau says : " This change in the character of the infant, the 
fear which it experiences of seeing its sufferings return, which the pressure 
of another's hand causes, this habitual sadness impressed upon its features, 
differs from that which we observe at the commencement of other maladies, 
especially from that in the prodromic period of cerebral fevers. In truth, 
in an infant over whom this last and cruel affection is impending, we are 
able to excite again a momentary cheerfulness ; we are able, by exciting 
actively its spirits, to make it turn temporarily from this melancholy lan- 
guor, which constitute its habitual state. It is not thus in the rachitic ; 
the more you desire to arouse it, the more you solicit its movements, the 
greater will be its impatience. It is indifferent to the plays which it pre- 
viously loved. This .... habitual sadness in an infant, who, with an 
appetite rather augmented than diminished, sensibly emaciates, who has 
constantly acceleration of pulse coincident with profuse perspiration, these 
symptoms, I repeat, have positive significance when the infant does not 
cough or present any of the signs which induce us to believe in the occur- 
rence of tubercular phthisis." 

Febrile movement, manifested by acceleration of pulse, is common, al- 
though, in most cases, there is no decided exaltation of the external tem- 
perature, perhaps in consequence, in part at least, of the free perspiration 
to which these patients are subject. 

A bruit de soufflet of greater or less intensity, synchronous with the 
pulse, has frequently been heard in rachitic cases, when the ear was ap- 
plied over the anterior fontanelle. Drs. Fisher and Whitney, New Eng- 
land physicians, first called attention to this murmur, believing it to be a 
sign of chronic hydrocephalus. MM. Rilliet and Barthez heard it in cases 
of rachitis, and therefore concluded that the American observers had mis- 
taken the rachitic for the hydrocephalic head. Later observations have 
established the fact that this murmur possesses little diagnostic value. It 
is heard in healthy as well as diseased infants. Dr. Wirthgen detected it 
22 times in 52 children, all of whom, except four, were in good health. I 
have auscultated the anterior fontanelle in 29 infants, who were, with two 
exceptions, between the ages of three and thirty months. Most of them 
were well, or with trivial ailments, which would not affect the cerebral 
circulation. In most infants with a patent fontanelle a murmur can be 
distinctly heard synchronous with the respiratory act, and in 15 of the 29 
cases no other bruit could be detected, while in the remainder, namely, 14, 
a bruit synchronous with the pulse was heard at the fontanelle. 

The rachitic, as stated above, are liable to perspirations, which are pro- 
fuse about the head and neck, so as to moisten the pillow on which they 
lie. The respiration is more or less accelerated except in the mildest cases, 
in consequence of the flexibility and diminished elasticity of the ribs, and 
the lateral depression of the thoracic walls, which prevent full inflation of 
the lungs. 



I 



COMPLICATIONS. 95 

The urinary secretion is abundant, like the persiDiratiou. Daring the 
first and second periods it contains a large amount of the calcareous salts, 
since the lime which enters the system with the ingesta, and which, in the 
normal state is expended in the growth of bone, is eliminated from the 
system by the kidneys. 

The appetite in the beginning of rachitis is good, sometimes even better 
than in health ; but it gradually diminishes, as the disease increases in 
severity, till it is entirely lost. Diarrhoea alternating with constipation is 
common. With the continuance of febrile movement and loss of appetite, 
the patient soon begins to lose flesh, emaciation in the second stage being a 
prominent symptom. 

Since the rachitic patient sits or lies quietly, unable or disinclined to 
make exertion, the muscles become small and flabby from disuse. Deposi- 
tion of fatty matter may occur between the primitive muscular fasciculi. 

Rachitis in the female infant is attended by one serious consequence, 
namely, narrowing of the pelvic cavity, from the thickening, change of 
shape, and imperfect development of the pelvic bones. Rachitis, there- 
fore, in the female greatly increases the danger of childbearing, and may 
render it impossible. 

Complications. — Rachitis is often attended by certain serious complica- 
tions, the most common of which are inflammatory affections of the respira- 
tory apparatus. Bronchitis is one of the most common diseases during 
the age at which rachitis occurs, and even a mild form of it involves great 
danger if the ribs are soft and flexible or the thorax have the rachitic 
deformity. In these cases, since full inflation of the lungs is prevented, 
collapse more or less complete of certain of the lobules is apt to occur, 
increasing the amount of dyspnoea, and therefore diminishing the chances 
of recovery ; hence bronchitis is very fatal in infants who are decidedly 
rachitic. 

Imperfect digestion of food, and unhealthy alvine evacuations, common 
in rachitic children, frequently cause diarrhoea, and, after a time, intestinal 
inflammation. The diarrhoea, especially if it has become inflammatory, 
is apt to be obstinate and dangerous, the patient becoming emaciated 
and feeble. 

Internal convulsions, the so-called laryngismus stridulus or spasm of the 
glottis, has been observed in so large a proportion of cases, that its occur- 
rence in rachitis must be considered something more than mei-e coincidence. 
Elsiisser believed that he had discovered the cause of the laryngismus in 
craniotabes, but later observations have failed to establish the correctness 
of his views. Hypertrophy of brain, and chronic hydrocephalus, are also 
occasional complications. In cases of great deformity of the chest from 
rachitis, in which the lungs are more or less compressed, the pulmonary 
circulation is retarded and imperfect. This gives rise to congestion of the 
right cavities of the heart, with hypertrophy of this organ, and congestion 



96 RACHITIS. 

of the hepatic veius, liver, and portal system. Congestion of the portal 
system may be regarded as a cause of the diarrhoeal attacks. 

Diagnosis. — Diagnosis is easy, except in incipient or slight cases. The 
lesions which pertain so largely to the skeleton are readily detected. Bead- 
ing of the costo-chondral articulations occurs early, and is apparent to the 
sight. Enlargement of the joints of the limbs, arrested dental evolution, 
the state of the anterior fontanelle, the peculiar shape of the head, the 
sternal projection, and rachitic curvatures, indicate positively the rachitic 
state. Profuse perspiration upon the head and neck, and the general ten- 
derness of the patient, as evinced by his cries when moved or disturbed, 
are also important diagnostic signs. 

Prognosis. — The prognosis is favorable, as regards life, if rachitis is 
recognized at an early period, and properly treated. The vicious nutritive 
process may be arrested, and the patient recover with but slight deformity. 
If curvature of the long bones has occurred, and the head and thorax are 
misshapen, the patient under favorable hygienic conditions commonly re- 
covers from rachitis, but with permanent deformities. 

If there is that degree of spinal curvature in the dorsal region, and de- 
pression of the ribs, that respiration is, habitually, more or less accelerated 
and embarrassed, on account of compression of the lungs, the prognosis is 
unfavorable, since bronchial or pulmonary inflammation, occurring in this 
condition, is apt to be fatal. If there is much emaciation, and especially 
if diarrhoea is present, or of frequent occurrence, the prognosis should be 
guarded. In these cases there is probably waxy degeneration of important 
organs, which cannot be remedied. 

Treatment. — The correct treatment of rachitis is obvious when we 
consider its character and the nature of its causes. The indication is to 
restore healthy nutrition. This requires both hygienic and therapeutic 
measures. The apartment in which the child resides should be dry, airy, 
and plentifully supplied with light. He should be taken daily into the 
open air, in order to invigorate his system, but in such a way as not to 
increase his suffering, in consequence of his general tenderness. The diet 
should be appropriate for the age. It should be bland and easy of diges- 
tion, and, at the same time, sufficiently nutritious. Cleanliness of person 
and apartment, and clothing sufiicient to protect from vicissitudes of tem- 
perature, are requisite. The rachitic patient of the city should, if practic- 
able, be removed to a well-selected locality in the country. 

The medicines which are of undoubted efficacy in rachitis are cod-liver 
oil, and the vegetable and ferruginous tonics. Cod-liver oil should be ad- 
ministered in cases in which the digestive function is not seriously im- 
paired. If the oil is not readily digested, if it diminish the appetite, or 
if the patient is affected with diarrhoea, it should not be administered. 
Positive harm may, under such circumstances, result from its use. 

The compound syrup of the phosphates, the citrate of iron and quinine. 



SCROFULA. 97 

wine of iron, iodide of iron, the various preparations of cinchona, columbo, 
etc., are the medicines which, with or without cod-liver oil, are best calcu- 
lated to restore healthy nutrition.^ When complications arise, the treat- 
ment should be modified to meet the exigencies of the case. Most of the 
diseases which occur as complications, require treatment similar to that 
which is appropriate in their idiopathic form, but all measures of a de- 
pressing nature should be avoided. 



CHAPTER 11. 

SCROFULA. 

The term scrofula (scrofa, a pig, from the resemblance of the enlarged 
cervical glands of a scrofulous individual to a swine's neck) is applied to a 
diathesis which is characterized by increased vulnerability of the tissues 
(Virchow). The nutritive process of the tissues is readily disturbed even 
by trifling irritants or agencies in those who possess this diathesis ; and 
therefore the scrofulous are very prone to hyperplasia of the lymphatic 
glands, and inflammations of various parts. Inflammations which can 
properly be considei'ed as dependent upon this diathesis are, for the most 
part, subacute or chronic, and they are apt to occur in tissues which are 
seldom inflamed in those who possess a sound constitution. Inflammation 
of a scrofulous nature differs from ordinary inflammation in the fact of a 
greater cell formation and greater liability to cheesy degeneration of the 
inflammatory products. Moreover, the diathesis often modifies those in- 
flammations to which all persons are subject whether scrofulous or non- 
scrofulous, as coryza or bronchitis, rendering them more protracted and 
less amenable to the ordinary treatment. 

Scrofula is a disease chiefly of infancy and childhood. Manhood, espe- 
cially the first years of it, is not entirely exempt ; but scrofulous manifesta- 
tions after the age of twenty are feeble and infrequent, disappearing 
entirely as the individual advances towards middle life. The diathesis is 
most active prior to the age of ten years. 

Causes. — Scrofula is congenital or acquired. Parents who had scrofu- 
lous symptoms in early life, or who are in a state of decided cachexia, as 

1 In the New York Infant Asylum, four marked cases of rachitis are now under 
treatment. In three of these infants protracted diarrhoea, in which there is apt to 
be an excess of acid in the primtc via3, seemed to be the cause of the faulty nutri- 
tion. "We have found in these cases the compound syrup of the phosphates an eli- 
gible remedy, containing, as it does, one grain each of the phosphates of iron, 
potash, and soda, and two grains of the phosphate of lime in each drachm. 

7 



98 SCROFULA. 

from cancer, syphilis, iuterniitteut fever, or tuberculosis, are apt to beget 
scrofulous children. Insufficient nourishment of the mother during a con- 
siderable part of her gestation, and advanced age, and therefore feeble- 
ness, of the father, are occasional causes. Near blood relationship of the 
parents is recognized as a cause by most who have written on this diathesis, 
and to this fact has been attributed the scrofula of royal families. 

Again, those born with sound constitutions may acquire scrofula through 
anti-hygienic influences in the first years of life. Among the poor of New 
York we often observe one child in the family who presents scrofulous symp- 
toms, while the rest of the children are well, and in many cases we are able 
to trace back the diathesis to some depressing cause or causes, which were 
sufficient to effect the peculiar change in the molecular condition of the 
tissues which constitutes this disease. Obviously the causes of acquired 
scrofula are quite numerous. In the infant it is sometimes produced by 
insufficiency or poor quality of the breast-milk, or the use of artificial food 
during the period when breast-milk is required. Too protracted lactation 
also, especially if artificial food is almost wholly withheld, may cause it ; 
as may also, in those who have passed beyond the age of lactation, the 
continued use of a diet which is deficient in nutritive properties. 

Residence in damp, dark, and filthy apartments or streets may also pro- 
duce it. Hence, one reason of its frequent occurrence among the city poor. 
Residence in a small, crowded, and imperfectly ventilated apartment has 
been known to produce it, even with personal cleanliness, and a diet suf- 
ficiently nutritive. 

Scrofula may also be produced in those previously robust and of sound 
constitution, by diseases of an exhausting nature. The eruptive fevers, as 
small-pox, measles, and scarlet fever, if severe, occasionally have this result, 
or they render active the diathesis, which had hitherto been latent. In 
this city, where chronic eutero-colitis of infancy is common, I have some- 
times been able to trace the diathesis to it. 

Can a child affected with scrofula communicate it to others? Does 
scrofula possess a peculiar principle, a materies morbi, which is communi- 
cable to others ? No one believes in the infectiousness of scrofula, but there 
is a strong popular belief that it is communicable by contact, and some 
good pathologists and high authorities in children's diseases are inclined 
to believe that the popular opinion does have some foundation in fact. 
M. Bouchut, who holds that the scrofulous and tubercular diatheses are 
identical, says of scrofula that it has not been shown to be inoculable. 
"Nevertheless, if its contagiousness has not been demonstrated, we are not 
able to say that it will not be some day. The facts of vaccinia followed 
by impetigo, by scrofulous ophthalmia, and enlargement of the cervical 
glands attributed to the inoculation of scrofulous vaccine virus, and those 
of the contagion of phthisis by constant cohabitation, demand, at least for 
the present, a certain reserve." 



CAUSES. 99 

But scrofula differs widely in its nature from those diseases which are 
known to be communicable by infection or contact. It presents no analogy 
with them. We would not suppose, apart from observations, that a dia- 
thesis which consists in such a state or constitution of the tissues that they 
are easily wounded, possessed any inoculable principle, and, in my opinion, 
observations go to show that no such principle exists. How often do we 
observe children with scrofulous coryza, otorrhoea, or scrofulous cutaneous 
eruption, associating with others without communicating the diathesis? 

Vaccination, however, affords the best opportunity for determining 
whether scrofula is inoculable, and the very prevalent opinion of non- 
professional people, that it may be communicated and established through 
this operation, should have due weight. For it may be stated, as a rule, 
that a widespread popular belief in reference to a disease, which has ex- 
ternal manifestations, does have some foundation in truth. 

The following are the facts in reference to this matter : 

1st. It is the almost unanimous opinion of the most experienced vac- 
cinators that pure vaccine lymph taken from a vesicle pi"ior to the eighth 
day, never communicates anything but vaccinia. When another disease, 
as syphilis, is communicated by the use of the lymph, it is through the 
blood, which has been mixed with the lymph by careless puncture of the 
vesicle. This opinion, so strongly established by observations, also com- 
mands assent from its I'easonableness. 

2d. Vaccination of those w^ho are decidedly scrofulous with virus from • 
a healthy child, especially if the scab is employed, not infrequently pro- 
duces a sore which becomes covered with a thick and irregular crust, con- 
sisting in part of inspissated pus, and the sore is long in healing. In the 
scrofulous, also, impetiginous eruptions are apt to arise around the vaccine 
sore, and the axillary glands to become tumefied on the side corresponding 
with the vaccination. This gives rise to the belief on the part of friends 
that impure virus has been used, and scrofula communicated, while the 
fault is in the constitution of the child itself. The tumefaction of the 
glands, and the primary and secondary sores, gradually disappear, in 
most cases, leaving no ill effects, and with no subsequent manifestations 
of disease. 

3d. The vaccine crust from a decidedly scrofulous child, as it contains 
more or less animal matter, and is often pale, irregular, or broken, inserted 
in the arm of a healthy child, not infrequently produces an immediate 
inflammation with suppuration, so that the vaccine vesicle, if it forms, is 
soon broken, and an irregular sore and crust result, which present none 
of the appearances observed in the uncomplicated vaccine erruption. A 
simple inflammation, produced by the pus or other products contained in 
the scrofulous scab, has coexisted with, and modified the specific eruption. 
The sore heals gradually, and im])etigiuous eruptions may occur around it, 
but no struma remains or is communicated. 

4th. Scrofulous manifestations sometimes appear for the first time after 



100 SCROFULA. 

vaccinia, but they appear also after those analogous but severer eruptive 
fevers, namely, measles, scarlet fever, and small-pox. Those infectious ex- 
anthematic diseases which profoundly affect the constitution, it is admitted, 
may be a co-operating, if not a main, cause of scrofula, and is there any- 
thing unreasonable in the supposition that vaccinia may have occasionally 
a similar effect, though less frequently or in a less degree, in proportion as 
it is milder? From my own observations, I am of opinion that vaccinia, 
not vaccination, may occasionally awaken to activity the scrofulous dia- 
thesis, or, in combination with other causes, may even produce it in those 
who previously possessed good constitutions. It is a well-established fact, 
in the etiology of diseases, that causes which, in themselves, are entirely 
inadequate, or even insignificant, frequently produce disease in a system 
which other agencies have already prepared for it. Thus an excoriation 
gives rise to erysipelas, or a slight exposure to cold produces rheumatism. 
And so in those cases in which the friends have charged the production of 
scrofula upon vaccination, it has seemed to me that the most that could, 
with truthfulness, be alleged, was that the constitutional disease which 
had been produced by the operation, namely, vaccinia, was a subordinate, 
but, under the circumstances, a sufficient cause. 

The following is the most striking case of the apparent communication 

of scrofula through vaccination which I have met : D , West Fortieth 

Street, residing in a tenement-house, had no scrofulous affection, and was 
considered healthy till the age of eleven years. The remaining children 
of the family have never exhibited scrofulous symptoms. At the age of 
eleven years this boy was vaccinated from a scab, the source of which was 
not known, but by a physician whose practice was chiefly among the city 
poor. The sore produced was long in healing, and, before it had healed, 
the axillary glands, and those of the face and neck, began to be prominent 
and hard. From this time to the present, a period of six years, these 
glands have remained so large as to constitute a deformity, and certain 
other groups of glands, as those in the left infra-clavicular region and 
right groin, have undergone a similar hyperplasia. Examination of the 
blood by the microscope shows the absence of leucocythsemia. This case, 
at first view, certainly appears to be an example of the communication of 
scrofula through vaccination, and, for a time, I could interpret it in no 
other way. But when we recollect the facts already stated, namely, the 
improbability of the communicability of a diathesis of such a nature, how 
frequently scrofula is acquired by children of the tenement-house popula- 
tion, solely through the anti-hygienic conditions in which they live, the 
large number of scrofulous children in the crowded quarters of the poor, 
many of which have external ailments so that the conditions for commu- 
nication are present in a high degree if scrofula were contagious, while 
the instances of its apparent communication are very infrequent, is it not 
probable that cases like this are to be explained in the manner indicated 
above, and that scrofula is not transmissible by vaccination ? The facts. 



ANATOMICAL CHARACTERS. 101 

if they do not fully prove non-contagiousness, at least render it very 
probable. 

Anatomical Characters. — There are no ascertained anatomical 
changes in the blood which are peculiar to scrofula. As long as the ap- 
petite and general health remain good, and the local affections have not 
occurred, the composition of this fluid is, so far as known, unaltered. In 
the cachexia, which is present when the general health is impaired, the 
blood becomes impoverished, the red corpuscles lose a portion of their 
coloring matter, and the w'atery element predominates. 

Does the glandular hyperplasia of scrofula produce an excess of the 
white corpuscles ? Virchow says ( Cellular Pathology, Lect. IX) : " During 
the progress of an attack of scrofula, in which, if the disease run a some- 
what unfavorable course, the glands are destroyed by ulceration, or cheesy 
thickening, calcification, etc., an increased introduction of corpuscles into 
the blood can only take place as long as the irritated gland is still, in some 
degree, capable of performing its functions, or still continues to exist ; as 
soon, however, as the glands are withered or destroyed, the formation of 
lymph-cells likewise ceases, and with it the leucocytosis. In all cases, on 
the other hand, in which a more acute form of disturbance prevails, con- 
nected with inflammatory tumefaction of the gland, an increase of the 
colorless corpuscles always takes place in the blood." Although the 
glandular hyperplasia occurring in scrofula increases the number of white 
corpuscles in the blood, scrofula cannot be regarded as sustaining any 
causative relation to that great and constant increase of white corpuscles 
which characterizes the disease leucaemia ; for this disease, as remarked by 
Niemeyer, does not occur in childhood, when the scrofulous diathesis is ac- 
tive, but in manhood, when it has ceased to exist, or has become latent. 

The anatomical change which a lymphatic gland, when it becomes the 
seat of scrofulous disease, undergoes, consists in an exaggerated production 
of the lymphatic cells, while an increase in the amount of stroma is quite 
subordinate, or none at all. The hyperplasia sometimes occurs gradually, 
and without the signs characteristic of inflammation ; in other cases it 
presents all the features of a true inflammatory process. Caseous degene- 
ration is the more apt to occur, the larger the number of newly formed 
cells, and the greater their mutual pressure. 

The hyperplasia is sometimes primary, a direct result of the diathesis. 
In other instances it is secondary to some adjacent inflammation, the mor- 
bid process being propagated along the lymphatic vessels. Thus, while 
primary hyperplasia of the cervical glands is not infrequent in children 
who have a decided scrofulous diathesis, secondary hyperplasia of these 
glands is more frequent. It results from eczema of the scalp, or face, or 
otitis, or any of the various forms of stomatitis. And so pharyngitis often 
gives rise to hyperplasia of the tonsils, which are lymphatic glands. The 
scrofulous nature of the glandular enlargement is apparent from tlie fact 
that it continues long after the primary inflammation, which gave rise to 



102 SCEOFULA. 

it, has abated ; for lymphatic glands sometimes become tumefied in those 
who are not scrofulous, either from direct injury or propagated inflamma- 
tion ; but the tumefaction is commonly less in degree, and in most in- 
stances it soon abates when the exciting cause is removed. 

The glands which most frequently undergo scrofulous enlargement are 
the cervical, inguinal, bronchial, and mesenteric; but in those who are 
highly scrofulous, the glands in the vicinity of any protracted inflamma- 
tion are very prone to hyperplasia, and sometimes become cheesy. Thus, 
I have seen enlarged and cheesy glands in the vicinity of bone which was 
affected by scrofulous ostitis, or periostitis. 

Glands enlarged by scrofula frequently remain indolent for many 
months or years, undergoing no appreciable alteration ; but they are lia- 
ble to attacks of acute inflammation, when they enlarge, become tender, 
and the surrounding connective tissue infiltrated and hard. Suppuration 
is the common result, and the abscess, if subcutaneous, escapes through 
the skin, leaving a cicatrix which is permanent. 

More frequently, with proper therapeutic and hygienic measures, the 
glandular hyperplasia gradually abates after a longer or shorter period, 
probably by fatty degeneration, liquefaction, and absorption of the re- 
dundant cells. Even when suppuration occurs in certain of the glands, 
others, and the majority, return to their normal state in this gradual way. 
Calcification of a gland has been known to occur, but it is rare. 

In order to complete the description of the anatomical characters of 
scrofula, it would be necessary to describe the various inflammations to 
which the diathesis gives rise. It will suffice, however, in this connection, 
simply to enumerate them. Those which are most common and of chief 
importance, occur in the skin, mucous membrane, connective tissue, the 
bones with their periosteal covering, the joints, and the two important 
organs of special sense, the eye and ear. 

Symptoms. — The scrofulous diathesis is exhibited by certain physical 
signs, which are present in infancy, but are more manifest in childhood. 
In one class of strumous children, they are as follows : Form, tall and 
slender; quickness of movement and perception ; intelligence, good; skin, 
thin and semi-transparent, through which the superficial veins are distinctly 
seen ; features, delicate ; cheeks, habitually pale or florid, and flushed by 
slight excitement ; eyes, bright, with bluish conjunctiva ; muscles and 
bones, slender in proportion to their length. Those children who present 
these peculiarities are said to have the erethitic form of the diathesis. 

Others have what has been designated the torpid scrofulous habit, which 
is characterized by softness and flabbiness of the flesh, distended abdomen, 
large head, broad face, slow, languid movements, and an over-production 
of fat in the subcutaneous connective tissue in certain situations, espe- 
cially the nose and upper lip. Though typical cases can be readily re- 
ferred to one or the other of these forms, there are many cases which are 
intermediate. 



SYMPTOMS. 103 

One of the earliest of the scrofulous manifestations is a subcutaneous 
cellulitis giving rise to abscesses, commonly not large, with little surround- 
ing induration, little pain, tenderness, and heat, and slow in discharging; 
in a word, indolent. The most frequent seat of these abscesses is upon 
the extremities, but they may occur upon the scalp or elsewhere. They 
gradually heal when the pus escapes, their site being indicated for a con- 
siderable time by the depression and reddish discoloration of the skin, 
which gradually returns to its normal state. Ordinarily, these abscesses 
do no harm apart from the reduction of the general health which they 
effect, but when occurring in localities where the connective tissue lies 
upon the periosteum, as upon the fingers, periostitis may result, with de- 
struction of the surface of the bone. Again, thrombi may occur in the 
veins of the inflamed part, giving rise to emboli, embolismal pneumonia, 
and death. Specimens from such a case were presented by me to the New 
York Pathological Society in 1868. 

The scrofulous affections of the skin often also occur at an early age, 
even before dentition. They are more frequent in infancy than in child- 
hood. The most common are eczema and impetigo, and of rarer occur- 
rence, ecthyma and lupus. But all of these may occur in those who are 
not strumous or who do not present the characteristics of the strumous 
diathesis. 

Scrofulous affections of the mucous surfaces are scarcely less frequent 
than those of the skin. They present the ordinary features of mucous 
inflammations of a subacute and chronic character. 

Sometimes they occur without obvious exciting cause ; in other cases 
there is an exciting cause, as exposure to cold ; but the inflammation once 
established, continues on account of the diathetic condition. It is some- 
times a matter of doubt whether a mucous inflammation is of such a char- 
acter that it is proper to designate it scrofulous, especially if it occur upon 
such surfaces as are often the seat of ordinaiy inflammation. If the child 
has heretofore presented symptoms of scrofula, if the inflammation is sub- 
acute, and there is no apparent cause to originate or sustain it apart from 
the diathesis, it is probably of a strumous character. The diagnosis is 
rendered more certain by observing the effect of anti-strumous remedies. 
The most frequent of these scrofulous inflammations of mucous surfaces 
are coryza, tracheo-bronchitis, and conjunctivitis. More rarely, stomatitis, 
pharyngitis, vaginitis, and, according to some, entero-colitis, are of a stru- 
mous character. Coryza gives rise to snuffling respix'ation, the formation of 
crusts around and within the nares, and excoriation of the upper lip. The 
tracheo-bronchitis is attended by thickening of the mucous membrane, 
increased production of mucous and epithelial cells, and a loud tracheal 
rale, accompanying each inspiration. 

Strumous inflammation of the mucous membrane of the trachea and 
bronchial tubes is not a very infrequent disease in this city. It sometimes 
originates in a simple inflammation from cold, or the tracheo-broncliitis of 



104 SCROFULA. 

measles, or pertussis, but it is apt to continue, with its rales, cough, and 
scanty expectoration, for months, unless relieved by a jDroper course of 
treatment. 

Among the most common of the strumous affections, are inflammation 
of the eyelid, designated psorophthalmia, and that of the eye itself. The 
former is characterized by redness and thickening of the lids, detachment 
of the eyelashes, and inflammation and altered secretion of the "Meibo- 
mian glands;" the latter, namely, strumous ophthalmia, by pain, lachry- 
mation, photophobia, and a moderate degree of hyperi^emia of the affected 
organ. One of the most common serious results of strumous inflammation 
affecting the eye, arises from the conjunctivitis and keratitis, namely, the 
formation of phlyctenulse and ulcers on the margin of the conjunctiva 
and upon the cornea, fed by newly formed vessels. If not controlled by 
proper treatment, they may result in opacities more or less permanent, or 
possibly, worse still, in perforation, with its consequent ill effects. 

Inflammations of the external and middle ear have their origin very 
generally in the strumous diathesis. Occasionally there is an exciting 
cause of the otitis, as an injury, or severe constitutional disease like scarlet 
fever. Protracted otitis, whether external or internal, and especially that 
form of it which leads to ulceration, destruction of the ossicles, and caries 
of the petrous portion of the temporal bone, it is proper, in a large pro- 
portion of cases, to regard and treat as strumous. 

Inflammations of the skeleton, whether of the periosteum, bones them- 
selves, or the joints, are common in childhood. They sometimes occur 
without apparent exciting cause, but most frequently result from injuries 
of a trivial character. Some of the best observers and highest authorities, 
as regai'ds the surgical diseases of children, both in this country and Eu- 
rope, state that they do not consider these affections to be of a strumous 
nature ; while others regard them as manifestations of struma. After care- 
fully examining the reasons for this variance in opinion, I am convinced 
that the difference of views in reference to this matter occurs from a differ- 
ent understanding of the nature of scrofula. Those who state that the 
affections alluded to are not scrofulous, believe, so far as I have been able 
to ascertain, that scrofula and the tubercular diathesis are identical. As 
tubercles are not, as a rule, present in children who suffer from these affec- 
tions, it is therefore held that these affections are not scrofulous. If those- 
holding this belief were told, or could be made to believe, that scrofula is 
entirely distinct from the tubercular diathesis, that it is merely a name 
applied to a diathetic condition in which the tissues are easily wounded, 
there would probably be but one opinion as regards the scrofulous nature 
of these inflammations. For, as I have often had an opportunity to ob- 
serve, they occur in a lai'ge proportion of cases from very trivial injuries, 
showing a highly vulnerable state of the tissues. 

Holmes, in his useful and eminently practical Treatise on the Surgical 
Diseases of CMldreyi, says of one of the most common of the affections 



RELATION OF SCROFULA TO TUBERCULOSIS. 105 

alluded to, namely, morbus coxarius : " The afFectiou in question occurs 
very frequently in strumous children, a circumstance which has led to its 

being denominated strumous If by strumous be meant a state of 

the system which renders the subject of it prone to the deposit of tubercle 
in the viscera, I think that there is good reason for asserting that morbus 
coxarius often attacks children who are not strumous, i. e., who display no 
such tendency to the deposit of tubercle." Still, Mr. Holmes states " that 
there is that condition of the system which disposes its subjects to the 
development of low inflammations of various kinds," which is almost the 
full definition of scrofula, as understood by us. 

The stubbornness and frequent disastrous consequences of scrofulous in- 
flammation of the skeleton are well known. Nearly every bone, as well as 
its periosteum, is liable to this form of inflammation, but some are more 
frequently affected than others. Inflammation of the bone may terminate 
by resolution, by the formation of an abscess, or, and frequently, by carious 
or necrotic destruction of the bone itself. Necrosis is most apt to occur in 
the shafts of the long bones, caries in the spongy extremities of these bones, 
and in the spongy portions of the short bones. If abscesses form, the pus 
may finally escape from the system by a tedious ulcerative process, or, re- 
tained, may undergo cheesy degeneration. Scrofulous arthritis, if early 
detected and properly treated, may resolve, leaving no ill effect ; if other- 
wise, suppuration, ulceration, cartilaginous and osseous, and anchylosis, 
are apt to result. 

Scrofulous children are perhaps no more liable to inflammation of the 
internal organs than other children, but the inflammatory products are 
more liable to cheesy degeneration, and the prognosis is therefore less fa- 
vorable. The most frequent of these inflammations, and the one of chief 
interest, is pneumonia. Catarrhal pneumonia, so frequent in early life, 
whether primary or secondary, in connection with measles, pertussis, etc., 
is a disease often involving grave consequences in those who are decidedly 
scrofulous ; since, instead of resolving, the affected lung-tissue presents 
a strong tendency to caseous degeneration, ending in consumption of the 
lungs and death. I have most frequently noticed cheesy pneumonia 
during extensive epidemics of measles, as a complication or sequel of this 
disease. It may occur in those who are not scrofulous, if the vital powers 
are greatly reduced, but it is so much more common in the scrofulous, that 
some recent writers have designated this form of inflammation by the term 
scrofulous, instead of cheesy, pneumonia. From the fact, however, of its 
sometimes occurring in the non-scrofulous, the term cheesy or caseous, espe- 
cially, too, as it expresses the anatomical state, seems more appropriate. 

Relation of Scrofula to Tuberculosis. — It is now almost univers- 
ally admitted that rachitis is entirely distinct in its nature from scrofula, 
although till a recent period, some of the best writers upon diseases of 
children, as Barrier, held that it was one of the manifestations of the scrof- 



106 SCROFULA. 

ulous diathesis. Altbongh the peculiar anatomical changes in rachitis 
occur chiefly in the osseous system, which is so often the seat of scrofulous 
disease, yet the character of these changes is so different from those which 
are admitted to be of a scrofulous nature, and especially as a large propor- 
tion of the rachitic do not present evidences of a strumous diathesis, struma 
and rachitis are justly regarded as distinct maladies. 

Pathologists and writers on diseases of children are not agreed as to the 
relation of scrofula to tuberculosis. Some, as M. Bouchut, hold that the 
scrofulous and tuberculous diatheses are identical, believing tubercles a 
late manifestation of scrofula, while others, among whom occur the names 
of Jenner, Virchow, and Villemin, deny their identity, though admitting 
their close relationship. Let us consider the facts, some of which are of 
recent discovery, which show in what manner, or to what extent, scrofula 
and tuberculosis are related. 

1st. In scrofula the lymphatic glands are more frequently affected than 
any other part, a true hyperplasia of their cellular elements occurring. 
This hyperplasia occurs to a greater or less extent in the majority of 
marked cases, and, when persistent, is the most reliable sign of the dia- 
thesis. The cells, which are produced so abundantly in scrofulous glands, 
are, to all appearance, identical in character with the cells of which tuber- 
cles are composed. In other words, the physiological type of the tubercle 
cell is the normal cell of the lymphatic gland, and the proliferation of this 
cell, as we have already stated, produces the enlarged gland of scrofula. 
But it is to be observed, as showing the difference between scrofula and 
tuberculosis, that this cell is never found in the affections admitted to be 
scrofulous, in any other situation than in these glands, where they exist 
normally ; whereas, in tuberculosis, they are produced abundantly, not 
only in the lymphatic glands, but in various organs and tissues through- 
out the system, which contain no such cell in their normal state. More- 
over, the origin of this cell in the lymphatic gland is, according to Virchow, 
different in scrofula and tuberculosis. While in the former it is produced 
by segmentation of the lymphatic cells, in the latter it is produced from 
the cells or nuclei existing in the connective tissue of the gland, as it is in 
other situations. 

2d. It has already been stated that the products of scrofulous inflamma- 
tion are very liable to cheesy degeneration. In children, indeed, cheesy 
degeneration more frequently results from the scrofulous affections than 
from any or all other diseases. Take, in connection with this fact, the 
very important recent discovery that tubercles are caused, in a large pro- 
portion of cases, by particles of cheesy matter, detached from the main 
mass, and conveyed to the lungs or other organs, and we see another inti- 
mate relation between scrofula and tuberculosis. 

3d. While the above facts show the close relationship of scrofula and 
tuberculosis, other facts relating to their hereditary transmission show, in 



EELATION OF SCROFULA TO TUBERCULOSIS. 107 

my opinion, their non-identity. The children of syphilitic parents are 
very apt to acquire thereby a scrofulous diathesis, and be affected by scrof- 
ulous ailments, while they cannot, as a rule, be said to possess the tuber- 
cular diathesis, or exhibit any more tendency to tubercles than other chil- 
dren who are in a state of equal cachexia. This does not comport with 
the doctrine that the scrofulous and tubercular diathesis are one. Again, 
the infant of the parent who has advanced tuberculosis exhibits a great 
liability to tubercles, and less in degree to scrofulous ailments. If the 
diathesis of scrofula and tuberculosis were identical, we would expect that 
a larger proportion of these infants would exhibit scrofulous manifesta- 
tions, and a smaller proportionate number become tubercular, since scrofu- 
lous affections are so much more frequent than tubercles. 

4th. As favoring the view that there are two diatheses, writers have 
stated the fact, that the greatest liability to tubercles is at an age when 
scrofulous affections are rare, namely, from the age of twenty to thirty 
years. M. Bouchut attempts to reconcile this fact with his theory of one 
diathesis, by analogical reasoning, which does not seem to me to be sound. 
He holds that there are distinct groups of manifestations of the diathesis, 
according to the age or the time of its continuance, as in syphilis, and that 
tubercles are the last manifestation. But tubercles may occur at any age, 
even in infants of a few months. Indeed, they are more common at the 
age of two or three years than at ten or twelve. The reasoning of M. 
Bouchut does not, therefore, appear to invalidate the argument, for how 
can we consider tuberculosis an advanced stage of scrofula, when it may 
occur at any age or at any period in those affected with scrofula? 

5th. Recent investigations demonstrate that tuberculosis is less a dia- 
thesis than was formerly supposed, or than scrofula is admitted to be. 
That there is, and was previously, a tubercular diathesis in a majority who 
are affected with tubercles, cannot be denied ; but, on the other hand, 
there are those, and not a few, who become affected with tubercles from 
the operation of local causes solely, when there was no diathetic predis- 
position to them. Thus, an individual who has never presented any evi- 
dences of scrofula or tuberculosis, but whose system is perhaps in a reduced 
state from some cause, takes a pneumonia, and the inflammatory products, 
instead of undergoing absorption, become cheesy, and from this cheesy 
substance tubercles result in the manner already described. Local causes 
have developed a tuberculosis unaided by a diathesis. Such cases are not 
very unusual. Contrast with this the fact that in the causation of scrof- 
ulous ailments the scrofulous diathesis always plays a conspicuous part. 

6th. The following fact may be inferred from the foregoing, but it is so 
important in this connection, as showing the difference between scrofula 
and tuberculosis, that it is proper to consider it under a sepai'ate heading. 
Scrofula simply modifies the ordinary physiological or pathological pro- 
cesses, while in tuberculosis there occurs, in the tissue affected, a patho- 



108 SCROFULA. 

logical process which is peculiar. Thus in tuberculosis there is produced 
from the connective tissue, or more rarely from epithelial cells, a cell which 
under no other circumstances is produced in these parts; whereas if scrofula 
affects the same tissues, there is simply an increase in the normal histologi- 
cal elements or inflammation, with the ordinary inflammatory products. 

Prognosis. — As scrofula may be acquired through anti-hygienic influ- 
ences, so it may disappear or become latent through influences of an op- 
posite character. Therefore the manifestations of scrofula may be limited 
to a brief period, or they ^may occur at intervals through the whole of 
childhood and the first years of youth. When the diathesis is inherited, 
and fostered by unfavorable circumstances, the scrofulous affections appear 
earliest, are the most varied and severe, and continue longest. 

In most cases, with proper treatment, the prognosis is good, provided that 
there are no serious local ailments. Scrofulous manifestations gradually 
disappear, the diathesis ceases or becomes latent, and the health is fully 
re-established. Though the general health is restored, certain scrofulous 
inflammations, continuing for a certain time, and reaching a certain grade 
of intensity, produce permanent deformity or impairment of function. In 
unfavorable cases, death may occur from exhaustion due to protracted 
suppurative inflammation, or from tuberculosis resulting from the cheesy 
product of a scrofulous inflammation. Again, if the function of a vital 
organ is permanently impaired by scrofulous disease, the prognosis of any 
subsequent inflammatory affection of that organ is rendered much less 
favorable. 

Treatment. — Prophylactic. — Measures designed to prevent scrofula are 
impossible Avithout the co-operation of willing and intelligent parents. It 
is obvious that the prevention of congenital scrofula requires the treatment 
of disease or impaired health in the parent. If parents should be taught 
or should remember that good health in themselves is the necessary con- 
dition of the inheritance of a sound constitution in the child, and should 
adopt such therapeutic and regimenal measures as would procure this, 
the number of cases of inherited scrofula would be materially reduced. 

As the first years of life are very important, both for correcting the dia- 
thesis when inherited, and for preventing its development in those of sound 
constitution, care should be taken that the regimen of the child be such as 
would in no way produce deterioration of the general health. The nursing 
infant, if the mother is in poor health, should be provided with a healthy 
wet-nurse, for in young children the diathesis may be acquired solely by 
the use of food that is scanty or of poor quality. Those old enough to be 
weaned should have plain and nutritious diet, with a proper admixture of 
animal food. More or less outdoor exercise, and a residence in a salubri- 
ous locality with sufficient air and sunlight, are requisite. 

Curative. — As scrofula originates in a state of weakness existing in the 



TREATMENT. 109 

parent in the congenital, and in the child in the acquired, form of the dis- 
ease, and is characterized by feeble resistance of the tissues to irritating 
agents, the inference is reasonable that all tonics have, to a certain ex- 
tent, an anti-scrofulous effect upon the system. The ordinary vegetable 
tonics, and sometimes the ferruginous, are indeed useful in the treatment 
of scrofula. Employed in connection with proper regimenal measures, 
they are sufficient in many cases, to remove the diathesis after a time, or 
render it latent. Besides these medicinal agents, which tend to correct the 
scrofulous diathesis by their general tonic effect, there are certain others 
which experience has shown to be beneficial in the treatment of scrofulous 
affections, and which are, therefore, largely used. One of these is cod-liver 
oil, which contains iodine with numerous other ingredients. 

Cod-liver oil is useless or nearly so in the torpid form of the diathesis, 
which is characterized by an increased deposit of fat in the subcutaneous 
connective tissue, slow circulation, and sluggish muscular movements. 
On the other hand, in the treatment of the erethitic form it possesses real 
value. Its protracted use in such cases does so modify the molecular con- 
dition of the tissues that they are less liable to inflammation, and the dia- 
thesis is, therefore, rendered milder or removed. From one to three tea- 
spoonfuls, according to the age, should be given three times daily. While 
we frequently experience so much difficulty in administering it to adults 
affected with tuberculosis, and sometimes find it necessary to discontinue 
its use on account of its nauseating effect, scrofulous children rarely refuse 
to take it, and it does not seem to diminish their appetite. 

Iodine is justly celebrated as a remedy in the treatment of scrofulous 
affections, but it is a question whether it has not been overrated as a 
remedy for the diathesis itself. Iodine eraj)loyed internally is especially 
serviceable in glandular hyperplasia, and in scrofulous thickening and 
induration of the connective tissue and periosteum. In general, it should 
not be administered to children in its isolated state, on account of its irri- 
tating properties, but one of its compounds should be employed. The 
compounds which are chiefly prescribed in the treatment of scrofula are 
the iodides of starch, iron, potassium, and sodium. If, as is frequently the 
case, the patient is pallid, and his appetite poor, the iodide of iron should 
be preferred ; if not in this cachectic state, the iodide of starch. Pharma- 
ceutists prepare syrups of both these iodides, so that they can be readily 
administered to the youngest child. The iodide of starch may be admin- 
istered by dropping from one to five drops of the officinal tincture of iodine 
on a little powdered starch, and giving it in syrup. These iodides are 
preferable to the iodides of potassium and sodium for internal administra- 
tion to children, as they are not irritating to the mucous membrane, and 
the iodine is readily set free. Prof. Dalton has, indeed, demonstrated that 
the iodide of starch is decomposed in most of the rujuids of the Ixidy, and 
the iodine liberated. 



110 SCROFULA. 

In this city a large proportion of the scrofulous children are cachectic, 
and need iron, and the iodide of iron is more frequently employed than 
any other iodine compounds. • In the Outdoor Department at Bellevue it 
is daily prescribed for the scrofulous children, and with the best results. 
It is taken readily, and for a lengthened period without producing gastric 
symptoms. To a child of six months we give at this institution one drop 
three times daily, and to one of two years three drops, with or without 
cod-liver oil. 

The internal use of mercury as an antidote for scrofula is now generally 
discarded. Unless, perhaps, in those cases in which the diathesis is imme- 
diately dependent on syphilis, its use for this purpose, from what we know 
of its therapeutic effects, would probably be more injurious than beneficial. 
Walnut leaves, employed in various ways, either as a decoction, infusion, 
wiije, or extract, have been highly extolled for the treatment of scrofula, 
but their use has not met with favor in the profession, and comparatively 
few can speak from their own observations of their effect. 

Among the medicines which have been from time to time employed for 
the cure of scrofula, some of which have had considerable reputation, but 
Avhich have nearly fallen into disuse, may be mentioned sarsaparilla, ele- 
campane, couium, digitalis, horseradish, and certain compounds of silver, 
gold, arsenic, baryta, and bromine. From what we know of the nature of 
scrofula, it is probable that none of these has any effect upon the diathesis 
or upon scrofulous ailments, except such as improve the appetite and gen- 
eral health, like horseradish. The same hygienic measures are required 
in the treatment of scrofula as are demanded in the proi)hylaxis of it. 

The scrofulous affections require additional and special treatment. It 
would transcend the proposed limits of this paper to speak of the various 
measures, medicinal, mechanical, etc., which are demanded for their cure. 

It is the common practice to treat these glands, if they are subcutane- 
ous, by daily application over them of the officinal tincture, the compound 
tincture, or the compound ointment of iodine. It is my opinion, from ob- 
serving the effects of these agents, that they are too irritating for ordinary 
cases. Applied daily, they cause proliferation of the cells of the epi- 
dermis, so that in two or three days the thickening of the cuticle is greatly 
increased, and its external layer begins to exfoliate. It has appeared to 
me that what we observe in the epidermis illustrates, to a certain extent, 
what occurs in the gland underneath, as a result of active counter-irrita- 
tion. The gland does not resolve, its superfluous cells are not destroyed 
and absorbed, as was desired, but the treatment tends rather to increase 
the proliferation of the cells of the gland, or the formation in it of true 
leucocytes. We have seen that a local cutaneous inflammation, as eczema 
or impetigo, is apt to cause the neighboring lymphatic glands to enlarge. 
How, therefore, can we expect to reduce a glandular swelling by a mode 
of treatment which establishes a similar condition. I once produced, 



TREATMENT. Ill 

partly by accideut, such an araouut of vesication over an enlarged, hard, 
and apparently somewhat indolent gland, in an infant of fourteen mouths, 
that for a week I was very anxious lest a sore would result, which would 
heal with difficulty, or leave a permanent cicatrix, and yet, instead of dis- 
persion of the glandular swelling, the pathological processes were so pro- 
moted that suppuration and discharge of pus occurred by the time that 
the cuticle had reformed. If hyperplasia of the lymphatic glands could 
be cured by counter-irritation, it should have been in this case. 

The correct mode of treating these glands, therefore, as regards external 
measures, I hold to be, to apply the iodine preparations in such a manner 
that the largest amount of iodine will reach the glands by absorption, with 
little irritation of the skin. I am not prepared to state what is the best 
formula for the application of this agent. During the last few mouths, we 
have been attempting to determine this in the children's class at the Out- 
door Department at Bellevue, but our statistics of cases are not at present 
sufficiently complete or numerous to enable me to make a positive state- 
ment. I feel justified, however, from the observations already made, in 
recommending the following formulae, as preferable to the officinal prepara- 
tions which are commonly employed : 

1st. R. Potas. ioclidi, 5J ; 

Ung. stramonii, gj. Misce. 

To be rubbed over the gland several times daily. It should not be ap- 
plied as a plaster, as it is too irritating and will vesicate. I have known 
a glandular swelling, which had continued about three months, to dis- 
appear in as many weeks, under its use in connection with internal remedies. 
Glycerin may be employed in place of stramonium ointment. It makes 
a nicer preparation. 

2d. R. Liq. iodinii compositi, 
Glycerinte, equal parts. 

To be applied three times daily with thorough friction, but less frequently 
if the skin becomes irritated. In place of Lugol's solution, tincture of 
iodine may be employed, with perhaps a little larger proportion of glyc- 
erin. One of the chief advantages from the employment of glycerin 
with the stronger iodine preparations is that it prevents to a great extent 
the shrivelling and desiccating effect on the cuticle, rendering it soft and 
in a favorable state for absor^^tion. 

3d. R. Liquoris iodinii compositi, ,533. 
Aqua', 5 XV. jNIisce. 

To be kept constantly upon the skin over the gland by lint soaked with it, 
over which oil-silk may be applied to prevent evaporation. 

4th. In the Medical Pre us and Circular of August 3d, 1870, J. Waring 
Curran states that he has used with great success what he designates a new 
iodine paint, consisting of half an ounce of iodine, the same quantity of 



112 TUBEECULOSIS. 

iodide of ammonium, 20 ounces of rectified spirits, and 4 ounces of glyc- 
erin. I have never employed it, but presume from its composition that 
it is useful. If too irritating, it can, of course, be diluted. 

Mercurial ointments have been recommended by Avriters of reputation 
for the treatment of these glands. I have employed them, and known 
them to be employed, but cannot say that I have ever observed any bene- 
fit from their use whatever. In the children's class at the Outdoor De- 
partment at Bellevue we have discarded them entirely for this purpose, 
although both the citi'ine and white precipitate ointments, diluted with an 
equal quantity of lard, have been used with great apparent benefit for 
chronic coryza of a strumous nature, and also occasionally for external 
otitis of the same nature. 

In a paper read at the meeting of the British Medical Association in 
1870, by Mr. Jordan, the writer reccommends, as attended with success, 
vesication, not over the gland, but at a little distance from it, as, for ex- 
ample, behind the neck, for treatment of the cervical glands. But a mode 
of treatment which seems so unlikely to be beneficial requires stronger 
proof of its utility than has yet been presented. 

When the gland becomes actively inflamed, as indicated by increased 
heat and tenderness, and redness of the skin, applications of iodine are no 
longer proper. They increase the local disease. There is no longer any 
pi'obability of resolution of the glands, and poultices should be applied. 

In strumous conjunctivitis and keratitis the solution of sulphate of 
atropia, two grains to the ounce of water should be dropped three times 
daily into the eye. It relieves the photophobia, while it exerts a curative 
effect on the inflammation. To remove the phlyctenul^e and opacities, 
finely powdered calomel should be dusted into the eye every second day. 
For the otitis, injections of tepid water to which a little carbolic acid is 
added (gr. ij to iij to the ounce) should be employed, and afterwards a 
mild astringent. The reader is referred to other parts of this book, and 
to special treatises, for an account of the proper mode of treating strumous 
inflammations of the bones and joints and of the skin. 



CHAPTER III. 

TUBERCULOSIS. 

TuBEECULOSis occurs at any period of life. It is, indeed, more frequent 
in early manhood than previously ; but it presents peculiar features in 
children, and especially in infants. Like most other general diseases, 
tubei'culosis has a local manifestation which serves for diagnosis. This is 



TUBERCULOSIS. 113 

a small, round, nearly transparent granulation, designated tubercle, which 
is developed within a tissue, or upon its surface. In certain situations it 
departs from its typical rounded form, and is more or less flattened. It is 
firm to the feel, and, when fully developed, varies in size from a pin's head 
to a small pea. It has recently, in its various phases, been studied with 
great interest by pathologists in Europe, and to a certain extent in this 
country, and these investigations have already thrown considerable ad- 
ditional light on the nature of tuberculosis. 

The statistics of tuberculosis, previously to the last ten years, were not 
strictly accurate, since cheesy degeneration, of whatever part, was re- 
garded by most pathologists as always a tubercular lesion, and its pres- 
ence in the cadaver was therefore considered sufficient proof that the 
disease of which the patient died was tuberculosis, whereas it is now known 
to be, in many instances, a degenerated product of simple inflammation. 
I have preserved the records of the post-mortem examinations of thirty-six 
cases of tuberculosis occurring under the age of five years, having rejected 
all cases of cheesy degeneration when not accompanied by other evidence 
of tuberculosis. Thus caries of the vertebrae, with cheesy substance in the 
bony excavations, I have not considered tubercular. I have rejected one 
case in which three large cheesy bronchial glands lay in front of the 
carious vertebrae, inasmuch as there were no tubercles in the lungs or else- 
where. In another rejected case, the only lesions were empyema of the 
left pleural cavity, hyperplasia, and cheesy degeneration of the bronchial 
glands, and a single large cheesy nodule in the right lung. 

Etiology. — The tubercular diathesis may be inherited. Hence the 
well-known fact of tubercular families. Cases are not infrequent in which 
hereditary tuberculosis proves fatal before the death of the affected parent. 
The offspring of a tubercular parent does not, as a rule, have tubercles at 
birth; but the tubercular diathesis, at first latent, as in syphilis, manifests 
itself in a few weeks or months in the formation of tubercles, and in the 
consequent cough and emaciation. In two cases, however, in my collec- 
tion, a cough was observed, according to the statement of friends, as early 
as the second or third week. Under good hygienic conditions, the in- 
herited diathesis may remain latent or be removed. If both parents are 
tubercular, the offspring almost necessarily becomes so. 

Tuberculosis frequently results from prolonged anti-hygienic conditions 
in those previously healthy and of healthy parentage. It may result from 
residence in damp, dark and dirty apartments, from scanty or unwhole- 
some food, protracted and exhausting diseases, in fine, from any agency 
which gives rise to great and continued impoverishment of the blood. Age 
is a predisposing cause. Tuberculosis is comparatively rare under the age 
of one year, while it is not uncommon in wasted infants between the ages 
of two and five years. This remark is fully substantiated by the statistics 
of the Nursery and Child's Hospital and Infant's Hospital of this city. 

8 



114 TUBEECULOSIS. 

Is tuberculosis propagated by infection? Most physicians would answer 
in the negative, though in some countries, as in Italy, it is stated that the 
profession have long regarded it as mildly infectious. Every physician 
of experience must have remarked the frequency with which tuberculosis 
occurs in those not predisposed to the disease, but who have been in inti- 
mate relation with consumptive patients. This has been commonly re- 
garded as due in no way to infection, but has been thought to be a coiuci- 
dence, or has been attributed to an influence not fully understood, which 
the emotions or imagination exerts in the causation of diseases. But 
recent discoveries concerning the etiology of tuberculosis, which will pres- 
ently be related, afford ground for the opinion which some of our best 
authorities in the pathology of tuberculosis, as Waldenburg, now hold, 
that minute particles exhaled or expectorated from the lungs may be the 
medium of infection. 

In December, 1865, M. Villemin read before the Academy of Medicine 
of Paris and published his celebrated memoir, which contained the results 
of his experiments in inoculating certain lower animals with tubercular 
matter. Since then the fact has been established by many experiments, 
that tubercle may be pi'oduced in the rabbit and other animals by insert- 
ing under their skin various pathological products, whether tubercular or 
non-tubercular, as gray tubercles, cheesy products, thickened pus, etc., and 
by inserting finely divided foreign substances, not animal, as anilin blue, 
and also by traumatic irritations which gave rise to the formation of in- 
flammatory products under the skin, as the use of a seton. The coloring 
matter, whether introduced alone or in combination with a pathological 
substance, is found in the tubercle which results in the lungs or elsewhere. 
Therefore, it is inferred that tubercle in these experimental cases is pro- 
duced by minute particles of the inserted substance, which enter the circu- 
lation and are deposited in the lungs or other organs. Where they are de- 
posited, inflammation (formative irritation) occurs, with proliferation of the 
cellular elements of the part. This corpusculation produces the tubercle. 

The importance of these discoveries is apparent. Cheesy substances 
produced in the system, whether in the lungs, lymphatic glands, bones — 
as in vertebral caries — or elsewhere, and also long retained purulent col- 
lections, as in empyema, may give rise to tuberculosis, provided particles 
of the morbid substance gain admittance into the circulation. 

Blood extravasated in the alveoli of the lungs, and undergoing degene- 
rative changes, is considered a cause of tuberculosis ; but such extravasa- 
tions are rare prior to the age of puberty. Protracted inflammation of the 
air-passages, as bronchitis or laryngitis, is stated to give rise to tubercles 
in certain cases, but it is not easy to see how this could occur except when 
the inflammation has extended to the lungs or given rise to cheesy de- 
generation of the contiguous glands. In infancy and childhood the com- 
mon cause is a diathesis inherited, or acquired through impoverishment of 



ANATOMICAL CHARACTERS. 115 

the blood by previous disease or anti-hygienic conditions, or it is infection 
of the system from cheesy glands or purulent collections. 

Post-mortem examinations in connection with these recent discoveries 
demonstrate that the immediate cause of the formation of tubercles in the 
lungs, spleen, and other viscera, in certain cases, is hyperplasia and cheesy 
degeneration of the bronchial and mesenteric glands, whether or not this 
glandular affection is to be considered tubercular. Thus in the last two 
cases which I have examined there were minute transparent tubercles in 
the lungs, some becoming yellow, evidently of very recent formation, and 
also in one of the cases in the spleen, while in both cases the bronchial 
glands were enlarged and cheesy, and in one also the mesenteric. In 
another case, occurring in the Child's Hospital, the bronchial and mesen- 
teric glands were cheesy, with all the thoracic and abdominal viscera 
healthy, while there were granulations nearly the size of a pin's head, due 
to cell proliferation, as ascertained by the microscope (tubercular), in the 
pia mater at the base of the brain, along its sides, and between the hemi- 
spheres. 

Cases are less frequent, but are occasionally observed, in which retained 
purulent collections appear to be the cause of the formation of tubercles. 
Thus, in 1870, 1 presented to the New York Pathological Society the lungs, 
containing minute, recent tubercles, removed from an infant, who had died 
when a few months old. The lungs were otherwise healthy, and there 
■were no cheesy glands, for which a careful examination was instituted ; 
but in the left thigh was a large deepseated abscess, which had been de- 
tected a month before death. 

Another, and probably the most frequent local cause of tuberculosis, is 
cheesy pneumonia. Caseous degeneration of the inflammatory products 
is common in young and feeble infants affected with pulmonary inflam- 
mation, and the supposition is reasonable that particles are more readily 
detached from a caseous mass in the lungs than in most other situations. 
Certainly, in this city, cases are not infrequent of young children present- 
ing the history of pneumonia, cheesy degeneration, and finally tubercles, 
especially during epidemics of measles. 

General Anatomical Characters of Tuberculosis. — Analysis 
of the blood of tubercular patients shows an increase in the w^ater, albu- 
men, fats, and white corpuscles, and a decrease in the number of red cor- 
puscles. The fibrin is slightly diminished, except in cases complicated by 
inflammation, in which it may be in excess. The chief interest, however, 
as regards the anatomical characters of tuberculosis, pertains to the 
tubercle. The tubercle is as characteristic of tuberculosis as the eruption 
is of an exanthematic fever. It is produced, as already stated, by a local 
proliferation or corpusculation. It is, therefore, a cell-growth, and not a 
deposit. 

If we examine with a microscope a thin section of a recent tubercle, we 



116 TUBERCULOSIS. 

will observe in its peripheral portion, in which proliferation was active at 
the time of death, large mother cells, spindle-shaped fibro-plastic cells, and 
small round cells, which have been released from the mother cells. This 
zone of proliferation often has considerable extent. Passing towards the 
central portion of the tubercle, we find these small round cells in gi'eat 
abundance. They represent a more advanced stage of the tubercle, since 
the central part is oldest. They are the most numerous cells in the tu- 
bercle, and they have been designated the tubercle-cells. They resemble 
closely in appearance the smaller of the white corpuscles of the blood, and 
cannot be distinguished from the normal cells of the lymphatic glands, 
each consisting of a single large nucleus surrounded by protoplasm. They 
are among the most fragile of i^athological cells. The cells are held to- 
gether by a transparent adhesive substance, which is firm and resisting. 

Every tubercle tends to undergo a molecular change by which its trans- 
parence is lost. This consists in a decay of the cells and the intercellular 
substance. Granules of fat are deposited within them, and the cells shrivel 
and disinteg)'ate. Fragments of cells, and shrunken cells, and cell-nuclei, 
are thus produced, which Lebert described as the tubercle-cells, and which 
were accepted as such by all observers till Virchovv ascertained their true 
character. The molecular change which I have described commences in 
the interior of the tubercle, and extends outward till the whole tubercle 
becomes opaque and yellow, and at the same time so friable as to be readily 
crushed between the fingers. The yellow tubercle is therefore only an 
advanced stage of the gray semi-transparent. 

It is evident that tubercle in its first period possesses vitality, and, like 
all neoplasms, has its bloodvessels. These are soon closed by coagula or 
granular fibrin, mixed with white blood-corpuscles. When the tubercle 
has reached the yellow transformation, its vessels are no longer pervious, 
but it is surrounded by a vascular zone, in which circulation continues. 
The subsequent history of tubercle is well known. It is seldom, perhaps 
never, absorbed. It softens, and henceforth, as has been said by a Ger- 
man pathologist, its history is that of an abscess. It is an irritant, pro- 
ducing inflammation in the surrounding tissues, with thickening and 
induration, and abundant production of pus-cells, which mingle with the 
tubercle elements. Ulceration and discharge of the liquefied substance 
upon one of the free surfaces is the common result. In exceptional cases, 
instead of softening, the tubei'cle may undergo fibroid degeneration or 
cretification. 

Anatomical Characters in Infancy and Childhood. — The ana- 
tomical characters of tuberculosis in the first years of life vary in certain 
particulars from the form which they present in the adult, but after the 
age of three years the differences are fewer and less pronounced than pi-e- 
viously. 

Tubercular laryngitis, so common in the adult, is absent in a large pro- 



LUNGS. 117 

portion of cases under the age of three years, and when present has little 
intensity ; and ulceration of the larynx very seldom occurs. This has 
been attributed to the fact that there is so little expectoration in young 
children, the sputum being an irritant. Niemeyer, however, does not con- 
sider the sputum of tuberculosis sufficiently irritating to cause laryngitis 
and laryngeal ulceration ; but the arguments in favor of this mode of 
causation, in my ojDinion, more than counterbalance those which have 
been presented against it. 

I have never »met a case of tubercular ulceration of the larynx or tra- 
chea in the post-mortem examination of young children, nor do I recollect 
ever treating a case in which there was that degree of dysphonia which 
.indicated ulceration. Rilliet and Barthez, in more than 300 necropsies 
of tubercular cases, found no ulcers in the larynx or trachea under the 
age of three years ; 8 cases between the ages of three and ten years, and 8 
between ten and fourteen years. The ulcers, whether seated in the larynx 
or in the trachea — and they are in most cases in the former, since the in- 
equalities upon the surface of the larynx favor the retention of the sputum 
— are commonly small, superficial, round or elongated, and with little 
thickening or inflammation of their borders. Occurring in the folds of 
the mucous membrane, for example, around the vocal cords, their form is 
usually elongated. 

Bronchitis is not infrequent. This inflammation is due to, and depend- 
ent on, the pulmonary tubercles, and is therefore most intense in the part 
of the lung w^here the tubercles are most abundant and furthest advanced. 
Consequently it is more intense on one side than on the other, and it may 
be unilateral. It differs in this respect from idiopathic bronchitis, Avhich 
is commonly pretty uniform on the two sides. It differs also in the fact 
that it is sometimes accompanied by ulcerations. The ulcers are round or 
elongated in the direction of the axis of the tubes, and, like those of the 
larynx or trachea, are superficial. Idiopathic bronchitis of infancy and 
childhood does not cause ulceration. Circumscribed inffammation may 
attack a bronchial tube, as indeed, the trachea, and give rise to ulceration 
and perforation, from the presence and pressure of a diseased lymphatic 
gland external to the tube. This subject will be treated of hereafter. 

Lungs. — It is well known that in the adult tubercles are always pres- 
ent in the lungs, if they occur in any part of the system. I have met two 
cases in which the lungs were free from tubercles in 36 post-mortem 
examinations of children who died of tuberculosis. One of the two was 
an infant, but its exact age is not stated in the records. It had cheesy 
degeneration of thymus and bronchial glands, enlargement of mesenteric 
glands, but without cheesy degeneration, and disseminated tubei'cles in 
liver and spleen. The other, fifteen months old at death, had tubercular ' 
meningitis, with numerous granulations upon the convexity of the brain, 
and the other usual lesions of meningeal inflammation, with bronchial 



118 TUBERCULOSIS. 

and mesentei'ic glands slightly enlarged and cheesy, and one of the former 
softened. In one case, then, in 18, the lungs had escaped the disease, 
Rilliet and Barthez state that they found the lungs non-tubercular in 47 
cases in 312, and Hillier did in 25 cases in 160. In their cases, therefore, 
the lungs were exempt from tubercles in about 1 case in 7. But it is to 
be recollected that the statistics of these observers were prepared at the 
time when all cheesy degenerations were thought to be tubercular, and 
the bronchial and mesenteric glands are sometimes cheesy when there are 
no tubercles or lesions referable to tuberculosis in any other part of the 
system. I have records of two such cases, which I i-eject from my stat- 
istics of tuberculosis, as there is no evidence that the disease was any- 
thing else than simple inflammation. Did I include these cases, my 
statistics would correspond with theirs. 

Pulmonary tubercles in children under the age of three years are, as a 
rule, discrete, and disseminated through the lungs. In cases at this age, 
which have advanced to a fatal termination, we commonly find yellow 
tubercles from the size of a pin's head to a shot in the different lobes, many 
still semi-transparent if the disease has been of short duration, but if pro- 
tracted most of them yellow, and here and there one softened and sur- 
rounded by condensed fibrous tissue. Around the semi-transparent or 
gray tubercles, many of which were growing, and therefore were in the 
state of active cell proliferation at the time of death, narrow vascular 
zones can often be detected by the naked eye. 

Under the age of three years, tuberculosis exhibits but little tendency, 
perhaps none, to affect the upper lobes sooner or in greater degree than the 
lower. 

The following are the statistics relating to the site of the tubercles in the 
lungs in the cases which I have examined. All, it is to be remembered, 
were under the age of three years : 

Cases. 
Tubercles disseminated throughout the lungs, . . .26 
Tubercles disseminated throughout the two upper lobes, . 3 
Tubercles disseminated through right middle lobe and left 

lower lobe only, 1 

Tubercles disseminated through left upper lobe onlj', . . 2 
Tubercles disseminated (few and semi-transparent) in left 

lung only, 1 

Tubercles disseminated in three points in right, and two in 

left lung, 1 

No tubercles in lungs, 2 



Between the ages of three and fifteen years, statistics show that the 
upper lobes are more liable to tubercles than the lower; but the difference 
in liability is not great. In many cases occurring in this period, the dif- 
ferent lobes are affected nearly simultaneously, and not very infrequently 



LUNGS. 119 

the upper lobe is the last which is involved. In October, 1866, I made 
the post-mortem examination of a boy who died in the Children's Service 
of Charity Hospital, at the age of fifteen years, and small scattered tuber- 
cles were found in the lower lobe of the left lung, while all other portions 
of these organs were healthy. Rilliet and Barthez, who include in the 
same statistics all cases from birth to the age of fifteen years, found gray 
semi-transparent tubercles 

Cases. 
In the right superior lobe in ...... 63 

In the right middle lobe in 43 

In the right lower lobe in ....... 55 

In the left superior lobe in 65 

In the left inferior lobe in . . . . . . .54 

The same observers found yellow tubercles in the 

Eight superior lobe in ....... 40 

Eight middle lobe in 28 

Eight inferior lobe in 39 

Left superior lobe in ........ 35 

Left inferior lobe in ........ 81 

It has already been stated that tubercle originates in a circumscribed 
inflammation. On the other hand, tubercle, especially when softening 
commences, is itself an irritant, exciting inflammation around it. In- 
flammation occurring from this cause is obviously likely to be protracted, 
continuing for weeks or months, unless the tubercular matter is eliminated 
by ulceration. The highly vascular and delicate lungs of the young child 
are very liable to inflammation when they are the seat of tubercles, and 
as the tubercles are disseminated, the pneumonia is commonly more ex- 
tensive than when it occurs from ordinary causes. In fifteen, or nearly 
one-half of the cases, there was pneumonia affecting portions of one or 
more lobes, or an entire lobe. From the extent and position of the solidi- 
fied portions, it was obvious that in most cases the inflammation origi- 
nated from the irritating effect of the tubercular matter, while in others 
it was due to hypostatic congestion, occurring in consequence of the long- 
continued recumbent position and the feebleness of circulation. In these 
fifteen cases the seat and extent of the inflammation were as follows : 

Cases. 

Nearly entire right lung, ....... 2 

Nearly entire middle and lower lobe, 1 

Entire left upper lobe, ........ 2 

A considerable part of both lungs, 1 

Posterior parts of both lower lobes, 4 

Posterior part of left lung, ....... 1 

Left lower lobe, and right middle and lower lobes, . . 1 
Left upper lobe (contained a large cavity) and posterior part 

of left lower lobe, 1 

Nodules of inflamed lung around tubercles. .... 2 



120 TUBERCULOSIS. 

The inflammation in about one-third of the cases was due to hypostasis, 
as it occurred in depending j^ortions, extended but little into the lungs, 
and sustained no relation to the amount of tubercle. It was in the stage 
of red, or more rarely of gray, hepatization. 

In seven of the cases there were pulmonary cavities as large in propor- 
tion as we ordinarily find in tuberculosis of the adult. The seat of one 
was in the right lower lobe ; of two, the left upper lobe ; of one, the right 
upper lobe ; of another, the right lung, its exact seat not stated ; and in 
the remaining case the cavity, which was the largest of all, occupied the 
interior of all three lobes on the right side. Some idea of the size of these 
cavities may be learned by the following extracts from the records : 1st 
Case. "A small superficial cavity communicating on one side with a bron- 
chial tube, and on the other side with a small circumscribed collection of 
pus in the pleural cavity." 2d Case. " Cavity of the size of a hickory- 
nut." od Case. " Cavity of the size of a large hickory-nut." 4th Case. 
"Cavity three-fourths of an inch in diameter." 5th Case. "A large ab- 
scess." 6th Case. " The cavity occupied nearly the whole of the interior 
of the left upper lobe." 7th Case. "About half the right lung excavated 
into a cavity which extended through the three lobes." 

Circumscribed pleuritis, produced by tubercles underneath the pleura, 
was observed in seven cases. It was ordinarily attended by little exuda- 
tion except the fibrin, but in one case a sufficient amount of serum had 
been exuded to compress considerably the lung. Pus was not observed 
in any notable quantity. 

Emphysema was present in several cases, chiefly in the upper lobes, 
sometimes vesicular, with fulness or bulging of the lung, an anaemic ap- 
pearance of it, and doughy, inelastic feel. In other cases emphysema was 
interstitial, producing little bladders of air under the pleura, especially 
towards the root of the lung, or separating the lobules by wedge-shaped 
or irregular interspaces filled with air. In one case air had escaped from 
an emphysematous bladder into the right pleural cavity, causing pneumo- 
thorax and collapse of the lung. 

Next to the lungs, the bronchial glands are more frequently diseased 
than any other organs, in the tuberculosis of infancy and childhood. 
They undergo the successive structural changes which characterize gland- 
ular inflammations, namely, hyperplasia, and more or fewer of them 
cheesy degeneration and softening. In the state of hyperplasia their firm- 
ness is diminished, and they have a pale flesh-color. Cheesy degenera- 
tion commences in one or more points in the gland, sometimes in the 
peripheral, sometimes in the central portion, and it extends till the whole 
gland presents the well-known cheesy appearance. When the gland 
softens, the thick liquid presents a puriform appearance, consisting of 
amorphous matter, fatty particles, and the shrivelled and disintegrated 
cells of the gland. Soon pus-cells occur, and their number increases. 



LUNGS. 121 

Microscopy shows no anatomical difference between the hyperplasia or 
cheesy degeneration of the lymphatic glands occurring from inflamma- 
tion, and that from tubercle; but since the bronchial and mesenteric 
glands are not often cheesy or greatly hyperplastic from simple inflamma- 
tion, and are commonly not only greatly enlarged but cheesy in the tu- 
berculosis of young children, we conclude that the inflammation which 
gives rise to this hyperplasia and degeneration in such cases is of a tuber- 
cular character. 

Rilliet and Barthez state that the bronchial glands were tubercular in 
249 cases in children, while the lungs were tubercular in 265 cases. All 
cheesy glands, it is to be recollected, they considered tubercular. In 4 of 
the 36 cases which I have examined, no record was preserved of the state 
of the bronchial glands ; in one case there was no perceptible hyperplasia 
and no cheesy degeneration ; in two there was hyperplasia, but no cheesy 
degeneration, while in the remaining twenty-nine cases there was cheesy 
degeneration of more or fewer of the enlarged glands, or parts of them, 
with occasional softening. In the fact that the bronchial glands are 
tubercular and enlarged, we have an explanation in part of the fact, that 
the symptoms in the tuberculosis of young children differ from those in 
the adult, since Louis found the bronchial glands tubercular in only 
twenty-eight per cent, of the adult cases of tuberculosis which he exam- 
ined, and Lombard in only nine per cent. A gland pressing upon the 
recurrent laryngeal or pneumogastric nerve, or the trachea, may give 
rise to dyspnoea and a cough ; or on the descending vena cava or one of 
the vense innominatse, to congestion of the brain and meninges, intra- 
cranial serous effusion, and even thrombosis in the cranial sinuses. The 
fact that a softened bronchial gland not infrequently is eliminated from 
the system, by ulceration, into a bronchial tube or the trachea, is well 
known. In one case which I observed the ulceration had destroyed por- 
tions of three of the cartilaginous rings of a bronchus, and the aperture 
was plugged by a cheesy fragment of a softened gland which protruded. 
Occasionally, it is stated by authors, the ulceration is into one of the 
large vessels of the mediastinum, or even into the oesophagus. 

The following is an example of bronchial phthisis, as it commonly oc- 
curs. This case, which is not included in the foregoing statistics, was 
seen almost daily by me during its entire progress. On September od, 1874, 
I examined an infant in the New York Infant Asylum, who had wheez- 
ing respiration during the last eight days. The wheezing occurred both on 
inspiration and expiration, and also, though less pronounced, during sleep; 
pulse 96, respiration 40, temperature normal. Its mother, who had charge 
of it, and had till recently wet-nursed it, had had unequivocal symptoms 
of tuberculosis for several months. The child was pallid, and its flesh 
was soft and flabby. The fauces were perhaps a little redder than usual, 
but were otherwise normal, and a careful exploration of the chest revealed 




122 TUBERCULOSIS. 

no cause of the embarrassed respiration. Auscultation and percussion 
gave a negative result. In the latter part of September a troublesome 
diarrha?a occurred, which continued more or less till near death. The 
temperature on September 28th, October 8th, 10th, and 11th, was lOOP, 
100°, 991°, and 100°. The pulse on October 10th and 11th was 120 and 
126. On October 8th the percussion-sound over the upper part of the 
right lung, seemed somewhat duller than on the other side, though the 
respiration was not observed to be notably changed in the area of the 
dulness. There was but little cough during the entire sickness. Death 
occuri'ed on October 20th. At the autopsy the bronchial glands were 
found enlarged and cheesy, and underneath the right bronchus, near the 
bifurcation, was a softened, almost diffluent gland, as large as a small 
hickory-nut, and compressing the bronchus. This, no doubt, had pro- 
duced the wheezing respiration, which had been the chief local symptom. 

The lungs, spleen, and in less degree 
the liver, contained numerous small 
miliary tubercles. Certain of the mes- 
enteric glands were also cheesy, but 
to less extent than the bronchial. The 
disease of the bronchial glands was 
evidently primary, the tubercles of 
the lungs and abdominal organs be- 
^ ing apparently quite recent. The ac- 

companying woodcut, from a photo- 
graph by Mr. Mason, the photogra- 
4 pher at Bellevue Hospital, represents 
-) a posterior view of the lungs and air- 
--^ passages. 

In no case have I found tubercles in 
the heart or pericai'dium, though they have been observed in rare instances 
in the latter. The mesenteric glands were enlarged by hyperplasia, and 
more or less cheesy, in 30 cases ; in their normal state, to appearance, in 
two cases, and in the remaining four cases their condition was not stated. 
In most of the cases the mesenteric glands were smaller and less cheesy 
than the bronchial, but in a few instances they were larger than the bron- 
chial and moi-e cheesy. 

It is a noteworthy fact, as bearing on the causative relation of these 
glands to tubercles, that not infrequently the amount of hyperplasia and 
cheesy degeneration of the former was very considerable, while the tuber- 
cles in the lungs or elsewhere were small, even minute, semi-transparent, 
and evidently of recent formation. 

Abdominal Viscera. — In children, tubercles in the solid organs of 
the abdomen rarely give rise to appreciable symptoms, as they are small 
and disseminated, not impairing materially the function of the part in 



ABDOMINAL VISCERA. 123 

which they are located. On the other hand, peritoneal and intestinal 
tubercles, and the enlarged and cheesy mesenteric glands, give rise to 
symptoms which require description. The most frequent seat of perito- 
neal tubercles is upon the attached surface of the peritoneum, where they 
are formed from the connective tissue. They are distinctly seen through 
the peritoneum, and cause some prominence of it. Exceptionally their 
seat is upon its free surface. Every portion of the peritoneum, whether 
visceral, parietal, or omental, is liable to tubercles, but general tuberculi- 
zation of so extensive a surface does not occur in any one case. The tu- 
bercles are spherical or lenticular, and most of them small. Sometimes 
they are very numerous, but so minute as to be scarcely visible. They are 
gray or yellow, according to the age. Peritoneal tubercles often produce 
circumscribed peritonitis, causing adhesion of opposite surfaces. The tuber- 
cles in themselves cannot be detected by palpation ; but masses or plaques 
composed of tubercles and inflammatory products are sometimes so large 
that they can be felt through the abdominal walls. 

The symptoms of peritoneal tuberculosis are attributable, for the most 
part, to the peritonitis. Among them may be enumerated abdominal ten- 
derness or pain, meteorism, ascites — usually slight — and derangement of 
the bowels, commonly diarrhoea. As tubercles in this situation occur, in 
most cases, subsequently to tubercles elsewhere, the symptoms which have 
been described are associated with and are subordinate to others. 

Stomach and Intestines. — The most common seat of gastro-intestinal 
tubercles is the small intestine, and more frequently its lower portion, 
near the ileo-ccecal valve, than its upper or central. They are rare in the 
duodenum or contiguous part of the jejunum. They are developed ordi- 
narily in the connective tissue, either that lying under the mucous or the 
serous surface. 

Gastro-intestinal tubercles are often accompanied by ulceration of the 
adjacent mucous membrane. But in a certain proportion of cases there is 
probably no causative relation of the tubercles to the ulcers, for ulcera- 
tion of this membrane is not infrequent in the tuberculosis of children, 
when there are no tubercles in the walls of the stomach or intestines. The 
following statistics of Rilliet and Barthez, relating to this point, will aid 
in an understanding of the symptoms : 

r,^ , , . 11 i- . IT r with ulcers, 6 cases, 

lubercles in walls oi stomach, 7 cases, • ' 

(. without " 1 case. 

TJlcers of gastric mucous membrane, without gastric tubercles, 14 cases. 

r^ , , . 11 • X .• on f with ulcers, 70 cases. 

Tubercles in small intestines, 82 cases, < ' 

t. without " 12 " 

Ulcers without tubercles in small intestines, 51 cases. 

„,,,., • . , • 1 - f with ulcers, 10 cases, 

lubercles in large intestines, lo eases, < . , 

° I without " 5 " 

Ulcers in large intestine, without tubercles, 47 cases. 



124: TUBERCULOSIS. 

The ulcers have vascular, thickened, aucl infiltrated borders. Their 
diameters vary from a line to half an inch or more, and their general form 
is circular, or, if two or more unite, irregular. Tubercular ulcers of the 
stomach are mostly in the great curvature, those of the small intestines in 
the ileum and lower part of the jejunum, and those of the large intestine 
in the coecum. 

The following table exhibits the stafe of the principal abdominal vis- 
cera in the 36 cases : 

Liver. Spleen. Kidneys. 

Tubercular, V2 22 1 

Non-tubercular, ...... 16 6 21 

^'ot stilted, 8 8 14 

Fiitty, 5 

In no instance did I observe tubercular softening in the abdominal 
organs, and a large proportion of the tubeix'les in the liver, spleen, and 
kidneys Avere still in the first stage. In the five cases in which the liver 
was recorded fatty, this state of the organ was obvious to the sight, as it 
is in tuberculosis of the adult. A moderate excess of fat in the hepatic 
cells may have been present in some of the other cases, but it was not 
sufficient to be appreciable without the microscope. It is to be remarked 
that in the five cases in which the liver was recorded fatty, this organ 
contained no tubercles. The spleen is seen to have been the most frequent 
seat of tubercles of all the viscera, except the lungs. In fourteen cases 
the intestines were examined ; and in five, tubercles discovered developed 
in their connective tissue. The intestinal tubercles were small, and ulcera- 
tion had occurred of the mucous membrane which covered them. 

The brain was examined in fifteen cases. In twelve cases the amount 
of cerebro-spinal fluid varied from sss. to v, by estimation. In two others 
the records state that there was a considerable amount of this fluid, the 
exact (juantity not being given, while in the remaining case congestion of 
the brain and meninges was noticed, but nothing was recorded in regard 
to the amount of cerebro-spinal liquid. The increase of the cerebro-spinal 
fluid in tuberculosis is attributable to wasting of the brain, a hydrocepha- 
lus ex vacuo, and in some cases to passive congestion and serous transuda- 
tion, due to feeble circulation, or obstructed flow from the pressure of 
bronchial glands on the ves.sels within the thorax, as already stated. 

Tubercles were present in the pia mater in three cases : in two with 
fibrinous exudation ; in the other without fibrin or other evidence of in- 
flammation. 

Symptoms. — The symptoms in tuberculosis of children arise in part 
from the diathesis, and in part from the tubercles. Before the period of 
tubercles, there are signs of failing health, such as loss of appetite, flabbi- 
ness of the soft parts, or emaciation, lassitude, and loss of strength. These 
symptoms continue after the formation of tubercles, and increase. 



SYMPTOMS. 125 

The features are ordinarily pallid, but during the paroxysms of fever, 
to which tubercular patients are subject, they may be flushed. Lividity 
of the features, due to imperfect decarbonization of the blood, occurs, if 
there are enlarged bronchial glands which compress the vessels within the 
thorax, or if there is extensive pulmonary tuberculization, or pulmonary 
tuberculization, whether extensive or not, which is complicated by capil- 
lary bronchitis or pneumonia. 

The skin is nearly natural, or it loses its flexibility and softness, and 
becomes dry and rough. In some patients there is, at times, general or 
partial furfuraceous desquamation of the skin, due to exaggerated de- 
velopment of the epidermis. Children, like adults, notwithstanding the 
general dryness of the surface, are liable to perspirations at night and in 
sleep. This symptom is less frequent at the commencement than at an 
advanced period, and in acute than in chronic cases, in the very young, 
namely, those under three or four months, than in older children. It is 
more abundant about the head and limbs than elsewhere, and is some- 
times confined to these parts. 

Anasarca is not infrequent. It sometimes arises from obstructed circu- 
lation, in consequence of compression of the thoracic vessels by enlarged 
lymphatic glands ; in other cases it is due to diminished plasticity of the 
blood, a result of the tubercular cachexia. The latter is the more com- 
mon cause. It is not an important symptom, on account of the small 
amount of serous transudation, and the character of the parts in which it 
occurs. 

Emaciation, already alluded to, is early, constant, and progi'essive. Under 
the age of six or eight months it is less marked than in older children, 
many preserving considerable rotundity of features and form even in ad- 
vanced tuberculosis. The failure of the strength corresponds in amount 
and progress with the emaciation. Slight at first, and exhibited only by 
a degree of lassitude, it gradually increases, till for weeks before death the 
little patient is fatigued by the ordinary muscular movements, and is dis- 
posed to keep quiet. 

The nervous system is not ordinarily affected except in cases of intra- 
cranial tubercles. In acute tuberculosis, or tuberculosis complicated by 
severe inflammation, there may be agitation and delirium, especially at 
night. 

In most patients the mucous membrane of the buccal cavity presents its 
normal appearance, with the exception of a moist fur upon the tongue, 
and a paler hue than normal of its surface generally In acute tubercu- 
losis, and in cases complicated by inflammation, the tongue is sometimes 
dry and brown. The appetite may be normal till the close of life, or it is 
poor or changeable. Occasionally it is increased, although the disease is 
progressing. The bowels are regular or relaxed. Diarrhoea may be a 



126 TUBERCULOSIS. 

prominent symptom, even when there are no intestinal tubercles or ulcera- 
tion, Meteorism and fulness of the abdomen are common. 

Fever, constant, but usually with evening exacerbations, is rarely ab- 
sent. It continues for weeks or months. During the exacerbation the 
pulse rises to 120, 140, or even to 180 beats per minute, and there is a 
corresponding exaltation of the temperature, which in the latter part of 
the day, without inflammatory complication, ranges from 100° to 102° or 
103°. The fever is a symptom of diagnostic value as regards the nature 
of the disease, though it does not indicate the seat of the tubercles. 

In addition to the symptoms now described, there are special symptoms, 
due to tuberculization of the different organs. In young children, on ac- 
count of the fact already referred to, namely, the tendency to a generali- 
zation of tubercles, there is apt to be a blending of the symptoms which 
arise from different organs, but with care it is not difficult in most in- 
stances to isolate and refer them to their proper source. The following 
are the symptoms which arise from tuberculization of the more important 
organs. 1st. Encephalon. The symptoms produced by tubercles of the 
encephalon vary according to their seat and size, and the structural 
changes in surrounding parts to which they give rise. Meningeal tuber- 
cles, which are located for the most part in the meshes of the pia mater, 
and by preference along the course of the small arteries, are ordinarily 
small, not more than a line in diameter, and they may remain latent for a 
considerable time. In the majority of cases, however, they sooner or later 
cause meningitis, the symptoms of which are well known and need not 
be described. But tubercles in this situation do sometimes give rise to 
symptoms when there is no meningeal inflammation. They occasion con- 
gestion of the surrounding vessels, and serous transudation, and if developed 
on the under surface of the pia mater they may produce symptoms by en- 
croaching upon and irritating the brain ; for they are sometimes so much 
imbedded in the convolutions that careful examination is required in order 
to determine that they are meningeal, and not cerebral. Among these 
symptoms may be mentioned headache, frontal or occipital, sometimes 
intermittent, nausea, melancholy, and in certain cases the symptoms pro- 
duced by the serous transudation. 

The symptoms of cerebral are in part similar to those of meningeal tu- 
bercles, but in most cases others of a neuropathic character are present, 
which serve for differential diagnosis. The differences as regards the 
symptoms of different patients affected with cerebral tubercles are attribu- 
table in part to the fact that their size and rapidity of growth vary, but 
more to the difference in their seat ; for any part of the brain may be the 
seat of tubercles, though certain portions, as the cerebellum, are more fre- 
quently affected than others. 

The child with cerebral tubercles is quiet, but irritable and easily ex- 



SYMPTOMS. 127 

cited. Delirium is uot common, but many before the close of life exhibit 
a degree of mental dulness. The headache, common in cases of cerebral 
as well as meningeal tubercles, may be nearly general, or it is frontal, pa- 
rietal, or occipital, according to the seat of the tubercles. It is often lau- 
cinatiug, often intermittent. 

Clonic convulsions occur towards the close of life. Exceptionally they 
are among the earliest symptoms. Observations have failed to establish 
any relation between the seat of the tubercles and the localization of the 
convulsions. The convulsions may be unilateral, while the tubercles are 
in both hemispheres ; or general, while the tubercles are on one side only. 

The severity and duration of the convulsive attacks, and the frequency 
of their occurrence in tuberculosis of the brain, vary greatly in different 
patients. They have been attributed to softening of the cerebral substance, 
which sometimes occurs immediately around the tubercles, to local conges- 
tions excited by them, and also to serous effusions in the ventricles. The 
convulsions, sooner or later, end in paralysis or coma. 

Contraction, or tonic convulsion of certain muscles, is sometimes ob- 
served. Its most frequent seat is the muscles of the back, and of one or 
both of the lower extremities. It is a late symptom. It occurs in those 
cases in which there is softening around the tubercles, and usually in the 
muscles of the opposite side. 

Paralysis is also a late, but not an infrequent symptom. It is preceded 
by headache, and sometimes, as already stated, by convulsions. Occurring 
as a symptom of tuberculosis of the brain, it is due either to pressure on 
a cranial nerve, or to compression and perhaps softening of the cerebral 
substance. The paralysis may be paraplegic, commencing as feebleness 
of the lower extremities, and increasing until it becomes complete, or a 
more or less complete hemiplegia. In paraplegia due to tubercles of the 
brain, the cerebellum is, as a rule, their seat, while paralysis of one side, 
or of certain muscles of one side, indicates tubercles of the opposite cere- 
bral hemisphere ; but there are exceptions. Paralysis of the third cranial 
nerve gives rise to ptosis, of the sixth to paralysis of the external motor 
nerves of the eye, and therefore to internal strabismus. 

Feebleness or loss of vision, inequality, oscillation, and finally dilatation 
of the pupils, are not infrequent symptoms of tuberculosis of the brain, 
and they possess great diagnostic value. Atrophy of the optic nerve, 
causing amaurosis, sometimes results from tubercles as well as other 
tumors of the brain. Atrophy of this nerve occurs not only when the 
tubercles are so located as to press on the optic tract, in which case the ex- 
planation is apparent, but also, in certain patients, when the tubercles are 
in other parts of the brain. In these last cases it is thought by Brown- 
Sequard and others that the imperfect nutrition of the nerve is due to con- 
traction of its nutrient vessels, produced by the tubercles through reflex 
action. 



128 TUBERCULOSIS. 

In tuberculosis of the brain, symptoms pertaining to the respiratory, 
circulatory, and digestive systems are either absent or are quite subordi- 
nate to those of a neuropathic character. Slowness of the pulse, with or 
without intermittence, has sometimes been observed, and it is therefore a 
symptom of some diagnostic value. Towards the close of life both pulse 
and respiration are apt to be accelerated. Vomiting, constipation, and 
retraction of the abdomen, which are so common in meningitis, are only 
occasional symptoms. 

Bronchial Glands. — During the progress of tuberculosis, hyperpla- 
sia, cheesy degeneration, and softening may occur of various lymphatic 
glands throughout the body, but the bronchial and mesenteric are not 
only those which are most frequently affected, but they are the only 
glands, unless in exceptional instances, which materially increase the dan- 
ger or give rise to special symptoms. These symptoms either have a me- 
chanical cause, namely, the pressure exerted by the enlarged glands on 
contiguous parts, or they are due to softening of the glands and consecu- 
tive inflammation and ulceration. 

The following are the principal symptoms due to compression. Some of 
them are not infrequent; others are rare. Compression of the pulmonary 
veins retards the flow of blood from the lungs to the left auricle, giving 
rise to congestion, and, in extreme cases, oedema of the lungs, with san- 
guineous extravasations into the lung-substance, congestion of the right 
cavities of the heart, hepatic veins, and of the systemic capillaries gener- 
ally. Compression of the pneumogastric nerve, or of the recurrent laryn- 
geal, which is the motor nerve of the laryngeal muscles, modifies the voice, 
and produces a cough which is apt to be spasmodic. The cough resem- 
bles that of pertussis, and has been mistaken for it, but it is not so violent 
or protracted. The voice, clear and natural at first, becomes by degrees 
hoarse or feeble from deficient innervation of the laryngeal muscles. 

An enlarged gland, or mass of glands, lying against the trachea or one 
of the bronchial tubes (this may occur with tubes up to the third or fourth 
division), and pressing its walls inward, obviously obstructs more or less 
the current of air. If there is considerable obstruction, a loud sonorous 
rale is produced, which is heard distinctly at a distance from the chest, 
obscuring other rales. It is loudest when the patient is agitated, and it 
sometimes intermits. Feeble respiratory murmur, dyspnoea, and a cough 
are not infrequent in bronchial phthisis. Diminished intensity of the re- 
spiratory murmur is gcnei-al or partial, according to the seat of the com- 
pression. It has been most frequently observed at the summit of the lungs. 
In certain patients this symptom is not constant, the respiration being for 
a time feeble and then normal. The dyspnoea may be a prominent and 
distressing symptom, the alae nasi dilating, and the infra-mammary region 
sinking with each inspiration. The cough which occurs when a gland 
pi-esses on the trachea or bronchial tube, is due to the tracheitis or bron- 



PHYSICAL SIGNS — LUNGS. 129 

chitis to which the pressure gives rise. If ulceration occur at the point of 
pressure, the cough continues as long as the ulcer remains. Compression 
of the large veins within the thorax, which return blood from the head 
and upper extremities, causes more or less congestion of these parts, with, 
perhaps, transudation of serum in the subcutaneous connective tissue, and 
within the cranium. Rarely a softened gland by ulceration gives rise to 
other symptoms than those mentioned, namely, hsemorrhage by ulceration 
into a vessel, or pleuritis or pneumonitis if the ulceration is towards the 
lungs. 

Improvement in the condition of the patient affected with bronchial 
phthisis is not unusual. It may be permanent, but in most patients it is 
temporary, so that in a few weeks or months the symptoms are as severe 
as before. The improvement is due to softening and elimination of a 
gland which had given rise to symptoms by its mechanical effect, or by 
the inflammation which it had excited. 

Physical Signs. — These are absent or obscure in the incipient disease, 
when the glands are small, and they are most marked in those cases in 
which the glands are so large as to press on the thoraeic walls, since the 
glands then become the medium for the transmission of sounds to the ear. 
The part of the thorax against which they most frequently press is the 
dorsal vertebrae, from the first to the sixth, and each side of the vertebrse, 
and less frequently the upper third of the sternum. The physical signs 
are dulness on percussion over the interscapular space, and perhaps, though 
to a less extent, over the upper part of the sternum, and bronchial respira- 
tion in the same situations. Occasionally a bruit can be detected, due to 
the pressure of a gland on one of the large vessels of the chest. 

Lungs. — A cough is one of the earliest and most persistent of the symp- 
toms of pulmonary tuberculosis. It is so rarely absent, that those of 
largest experience do not meet with more than one or two such cases. It 
varies in severity and frequency. If the tuberculosis is acute and its 
course rapid, the cough, even from its commencement, is frequent, so as to 
weary the patient and deprive him of needed rest. But in ordinary cases, 
namely, when the disease is chronic, the cough commences gradually, at- 
tracting little attention by its infrequency, but becoming more frequent 
and painful as the malady advances. 

Ordinarily the cough is dry in the first weeks or months, but it becomes 
looser in the course of the disease, from the greater amount of bronchial 
inflammation. In exceptional instances the cough has a spasmodic charac- 
ter, like that produced by pressure of an enlarged bronchial gland on the 
pneumogastric or recurrent laryngeal nerve. This occurs from the accumu- 
lation of viscid mucus in one or more of the bronchial tubes, usually in 
dilated portions of them, from which it is with difficulty expectorated. 

The respiration in pulmonary tuberculosis is accelerated in proportion 
to the degree of tuberculization. Tuberculization of a considerable part 

9 



130 TUBERCULOSIS. 

of both lungs gives rise to dyspnoea, especially when, as is ordinarily the 
case, bronchial, pulmonary, or pleuritic inflammation has supervened. 
Pneumonitis or pleuritis gives rise to the expiratory moan, and as these 
inflammations, when induced by tubercles, are protracted, this symptom 
may continue for weeks or months. 

Patients under the age of six years do not expectorate, or but rarely. 
After this age expectoration is not common in the commencement of pul- 
monary tuberculosis, but in the confirmed disease it is a pretty constant 
attendant of the cough. Haemoptysis is also rare under the age of six 
years, and less frequent subsequently than in the adult. It is most apt to 
occur in those cases in which there is already passive congestion of the 
lungs, produced by the pressure of enlarged bronchial glands in the man- 
ner already described. Patients old enough to make known the subjective 
symptoms, sometimes complain of fugitive pains under the sternum or 
between the shoulders. 

Physical Signs. — In young children the physical signs of incipient 
pulmonary tuberculosis are wanting, or are so obscure as not to be readily 
recognized. This is due to the small size and dissemination of the tuber- 
cles. In older children, because, as a rule, the tubercles are aggregated, 
and are more frequently at the apices of the lungs than elsewhere, as in 
the adult, the physical signs appear early, and are readily recognized. In 
the advanced disease, whether in infancy or childhood, when inflamma- 
tion and more or less destruction of the lung-substance have occurred, the 
physical signs, so far from being obscure, enable us in most cases, in con- 
nection with the history, to make an immediate and positive diagnosis. 

In young children affected with pulmonary tuberculosis the irregular and 
imperfect expansion of the lungs produces by degrees changes in the shape 
of the thorax, which are apparent on inspection. In some, the lungs being 
habitually imperfectly inflated, the obliquity of the ribs is increased, and 
the thorax consequently elongated, while its antero-posterior and trans- 
verse diameters are diminished. This obviously increases the convexity 
or arch of the diaphragm, so that this muscle sometimes lies against the 
thoracic walls as high as the ninth or even eighth rib. If the costal car- 
tilages are yielding, there is anterior flattening of the chest and depression 
of the sternum ; if they are firm, on account of the more advanced age, 
the chest remains circular. 

Another shape of the thorax is not infrequent in feeble tubercular 
children, especially infants, who have suflTered from repeated attacks of 
bronchitis. It occurs also in the non-tubercular, if the conditions which 
favor it are present. The conditions are, on the one hand, feebleness of 
the patient, with diminished force of respiration and impaired resiliency 
of the ribs ; and, on the other, obstruction by mucus of one or more of 
the bronchial tubes. Occlusion more or less complete, of a bronchial tube, 
and consequent obstruction to the current of air, produces a corresponding 



PLEURA. 131 

degree of collapse in the portion of lung to which the tube leads. The 
portions which collapse are, in most cases, the lower lobes, and the thin 
anterior margins of the upper lobes. This causes lateral depression of the 
lower ribs, except such as are pressed outward by the abdominal viscera, 
and an anterior projection of the lower part of the sternum. The shape 
of the thorax in these cases differs from that in rachitis, in the fact that 
the lateral depression does not extend to the upper ribs, nor does the up|)er 
part of the sternum project. 

Certain precautions should be observed in examining the chest by per- 
cussion and auscultation. The child should sit or recline, with the arms 
and shoulders in the same position, and the axis of the trunk straight. 
Inclination of the trunk to either side, raising or depressing a shoulder, 
may produce an appreciable difference in the two sides as regards the 
physical signs. Percussion of the two sides should be practiced at the 
same stage of respiration. A slight difference in the degree of resonance 
does not afford proof of disease, unless it is observed at different examina- 
tions ; for, in feeble children, it often happens that all portions of the 
lungs do not expand alike, so that where we have noticed slight dulness 
at one visit, it may by the next have disappeared, or even at the same visit 
if forcible inspirations are excited. 

The physical signs ascertained by palpation, auscultation, and percus- 
sion are, as in the adult, vocal fremitus, bronchial i^espiration, bron- 
chophony, and dulness on percussion. In those cases in which the tubercles 
are mainly at the apices of the lungs, diminished expansion of the infra- 
clavicular region is observed during inspiration, and this part of the 
thoracic wall is permanently depressed, so that the clavicles are unusually 
prominent. If there is emphysema, this flattening does not occur, or is 
slight. Dulness on percussion, though more frequently observed in the 
infra-clavicular region than elsewhere, may be present in different isolated 
places. If pneumonia supervene, the dulness not infrequently extends over 
a considerable part of one lung. The cracked-pot sound is often observed 
on percussion, but it possesses no diagnostic value. It can be produced, 
when there is no pulmonary disease, by percussing over a bronchus. 

Bronchial respiration and bronchophony, are important signs, as indi- 
cating solidification of the lung, but they do not show whether the solidi- 
fication is tubercular or pneumonic, or the two conjoined. This must be 
determined by the history of the case, the extent of surface over Avhich 
these signs are heard, and their persistence. When the tubercles begin to 
soften, and the lung-tissue breaks up, moist rales appear, often hoarse and 
gurgling, obscuring the bronchial respiration. A cavity in the lung, or 
pneumothorax, is attended by the same physical signs as in the adult. 

Pleuka. — Little need be said in reference to the symptoms and physical 
signs of tuberculosis of the pleura, since this affection is in most instances 
associated with tuberculosis of the lungs, and is not distinguishable from 



132 TUBERCULOSIS. 

it. But now and then the pleural tubercles are numerous and large, 
giving rise to symptoms, while those of the lungs are small, few, and 
Avithout symptoms, or attended by symptoms which are quite subordinate. 
Either the costal or visceral portion of the pleura may be the seat of 
tubercles. They are developed directly under the pleura, or upon its free 
surface. They are very apt to occur in the newly formed connective 
tissue which results from pleuritis. Those located upon the free surface, 
or under the costal pleura, rarely soften, while those under the visceral 
pleura sometimes soften and cause ulceration. Occasionally numerous 
aggregated tubercles form a firm continuous layer upon the surface of the 
pleura, preventing, if upon the visceral pleura, full expansion of the lung. 
This may give rise to a degree of dulness on percussion, and feebleness of 
the respiratory murmur. Ordinarily, however, in this form of tuberculosis, 
the symptoms and physical signs, so far as any are observed, are due to 
the pleuritic inflammation which the tubercles excite. 

Stomach and Intestines, — The symptoms in tuberculosis of the 
stomach and intestines vary according to the seat and stage of the 
tubercles. 

Tubercles, whether gasti'ic or intestinal, are not at first accompanied by 
symptoms, or the symptoms are obscured and ill-defined. Symptoms arise 
when inflammation occurs in the adjacent tissues. Diarrhoea is one of the 
most common and persistent of the symptoms. The alvine discharges are 
brown and thin, and sometimes in advanced cases very offensive. They 
may be streaked with blood which has escaped from the ulcers. Intestinal 
tubercles, developed immediately underneath the pei-itoneal coat, some- 
times cause local peritonitis, usually of little extent. This gives rise to 
circumscribed pain, tenderness, and more or less meteorism. 

Diagnosis. — It is evident from the foregoing description of symptoms 
that the diagnosis of incipient tuberculosis is much more difficult in chil- 
dren than adults. Before commencing the examination, it is advisable to 
learn the hereditary tendencies of the family and the history of the pa- 
tient, especially as regards antecedent diseases or debilitating agencies, 
and the duration of the symptoms. 

Tuberculosis of the encephalon is diagnosticated with more difficulty than 
that of the thoracic or abdominal organs ; but certain of these organs are 
ordinarily tubercular at the same time, and the knowledge of the fact 
that the}' are affected aids in the diagnosis of the disease of the brain or 
its meninges. Among the symptoms which possess diagnostic value may 
be mentioned cephalalgia and more or less fever, with exacerbations in the 
commencement of the disease, and at a more advanced period strabismus, 
inequality or irregular action of the pupils, impairment of vision, retrac- 
tion of the head, and convulsive movements or paralysis. 

In certain cases careful observation and discrimination of symptoms 
are requisite, in order to determine whether they arise from intra-cranial 



DIAGNOSIS. 133 

tubercles, or from congestion of the brain caused by obstruction in the 
venous circulation by the pressure of enlarged bronchial glands. 

The diagnosis of bronchial phthisis, when the glands are still small, is 
necessarily uncertain, on account of the absence of symptoms. When 
they have increased in size and are so located as to press on the pneumo- 
gastric or recurrent laryngeal nerve, producing the spasmodic cough already 
described, the differential diagnosis between that disease and pertussis may 
be made by attention to the following facts : Bronchial phthisis occurs 
singly, and is non-contagious, Avhile pertussis occurs as an epidemic, and 
with evidences of contagion. There are no successive stages, namely, those 
of catarrh, paroxysmal cough, and decline, as in that disease, and the cough, 
though paroxysmal, is short, and without hoop or vomiting. 

In feeble children, with inherited tubercular diathesis, emaciation, sweats, 
and a chronic cough, with the absence of pulmonary symptoms, should 
excite suspicions that the bronchial glands are involved. The evidence 
is almost conclusive if the cough becomes paroxysmal, and there is a loud, 
persistent, tracheal, or bronchial rale. 

In certain of the patients affected with this form of tuberculosis, we have 
seen that the prominent symptoms are due to compression of one or more 
of the large vessels in the chest. Compression of these vessels, and conse- 
quent retarded circulation, may be confidently referred to enlarged bron- 
chial glands, since aneurism, carcinomatous or other tumors, which would 
produce a similar result, are very rare before puberty. Sometimes the diag- 
nosis is rendered certain by the physical signs observed by auscultation, 
and percussion over the sternum and the interscapular space. The condi- 
tion of the external glands should also be observed, as those of the axilla, 
neck, and groin. 

The diagnosis of pulmonary, though more readily made than that of 
intra-cranial and bronchial tuberculosis, is often difficult and uncertain. 
This is,, in part, explained by the fact that the tubercles are so frequently 
disseminated, while emaciation and a chronic cough are not infrequent 
from other causes than tubercles. Rachitis, intestinal worms, dentition, 
simple tracheal or bronchial inflammation, may be attended both by a 
chronic cough and emaciation. Caution is therefore requisite in order to 
avoid a grave error in diagnosis. Precipitancy in the diagnosis of doubt- 
ful cases is worse than indecision, and it is often best to postpone an ex- 
pression of opinion as to the nature of the disease till the case has been 
observed for a few days. 

The significance and importance of the symptoms, physical signs, and 
other facts on which a diagnosis must be based, have already been suffi- 
ciently pointed out. It is difficult, in fact in certain cases impossible, to 
discriminate between simple cheesy pneumonia and cheesy pneumonia 
Avhich has ended in the formation of tubercles. The patient has an attack 
of catarrhal pneumonia; but, instead of absorption of the inflammatory 



134 TUBERCULOSIS. 

product, cheesy iufiltratioii occurs, aud the luug in places becomes infil- 
trated with pus, softens, and breaks down. The patient presents the symp- 
toms and physical signs of phthisis. He may recover after a protracted 
sickness, or may die. The disease may, and often does, remain a pneu- 
monia ; but this is a condition of the lungs which favors the development 
of tubercles, and in a certain proportion of cases tubercles do form in the 
last weeks of life. Though the difl'erential diagnosis in such cases between 
simple pneumonia and tuberculosis supervening on pneumonia is impos- 
sible, practically the discrimination is unimportant, as the same treatment 
is required. 

Advanced pulmonary tuberculosis, except when it supervenes upon 
pneumonia, can in most instances be readily diagnosticated by a careful 
examination. Stilly it is to be recollected, as already pointed out, that 
certain of the symptoms and physical signs, which occurring in the adult 
would afford almost positive proof of pulmonary tuberculosis, in children 
not infrequently have a different origin. 

The diagnosis of tubercles in the abdominal organs is facilitated by the 
presence of symptoms which indicate at the same time tuberculosis of the 
lungs. Among the chief diagnostic signs of tuberculosis of the peritoneum 
may be mentioned meteorism and a degree of tenderness on pressure. But 
there is danger of mistaking the tympanitic state of the intestines common 
in ill-nourished infants and the rachitic, or the fulness due to enlarged 
spleen or liver, to that occasioned by peritoneal tuberculization, and vice 
versa. The history of the case, and a careful examination of accompany- 
ing symptoms, aud the shape and feel of the abdomen, usually suffice to 
establish the diagnosis. In simple gaseous distension of the abdomen there 
is an absence of the symptoms, general and local, which attend tubercu- 
losis ; rachitis occurs at an earlier age than peritoneal tuberculosis, and 
digital examination, aided by percussion, enables us to diagnosticate en- 
largement of the liver or spleen. 

Tubercular enlargement of the mesenteric glands cannot be positively 
diagnosticated when they are small. When they have attained such a 
size that they can be felt through the abdominal walls, palpation in con- 
nection with the history and symptoms of tuberculosis suffices to establish 
the diagnosis. The glandular tumors can be diagnosticated from other 
tumors by the fact that they are tender on pressure, and occupy the um- 
bilical region, while foecal tumors are not tender, and are located in the iliac 
or lumbar region. Gastro-intestiual tuberculosis cannot be positively diag- 
nosticated. Protracted diarrhoea, or frequent attacks of diarrhoea, not 
readily controlled by medicine, and occurring in tubercular cases, are 
probably associated with intestinal ulceration ; but in only a certain pro- 
portion of cases of ulceration are there also tubercles in the walls of the 
intestines. 

Prognosis. — Death is the ordinary result of tuberculosis in the child, 



TREATMENT. 135 

as it is in the adult ; but now and then one recovers. Hospital statistics 
show that the average duration of the disease is from three to seven 
months. Under favorable circumstances it is more protracted, even to 
two or three years. Those succumb soonest who inherit a strongly marked 
tubercular diathesis, live in damp, dark, and ill-ventilated apartments, 
and whose diet is scanty or of poor quality. Therefore in the poor quarters 
of the city tuberculosis presents a worse form and pursues a more rapid 
course than among families in better circumstances. 

Favorable prognostic signs are absence of tubercular diathesis, good 
appetite and general health, with little emaciation, infrequency of cough, 
with respiration, pulse, and temperature nearly normal. Such symptoms 
may afford hope of recovery with judicious regimenal and therapeutic 
measures. On the other hand, if the symptoms are grave, death is inevit- 
able, unless in bronchial phthisis, in which, even when there is consider- 
able urgency of symptoms, the offending gland is sometimes eliminated 
by softening and ulceration, and the patient improves temporarily, if he 
does not ultimately recover. Complete and permanent recovery is, how- 
ever, quite exceptional. 

Death in tuberculosis of children may occur from exhaustion induced 
by the general disease, or from the local effect of the tubercles. Thus, in 
intra-cranial tuberculosis it may result from coma ; in pulmonary tuber- 
culosis, from dyspnoea, though more frequently from exhaustion ; in that 
of the bronchial glands, from coma, dyspnoea, exhaustion, or even from 
haemorrhage ; in that of the abdominal organs, from peritonitis or pro- 
tracted diarrhoea. 

Treatment. Projohyladic. — Though tuberculosis is so obstinate and 
fatal, it is often in our power, if forewarned, to avert it. A nursing infant, 
whose mother has the disease, should be immediately taken from the 
breast and intrusted to a wet-nurse. The health of the mother as well as 
infant requires this. If the father has the disease, and the mother's milk 
is inadequate or of poor quality, and the infant is under the age of six. 
months, the same change should be made, rather than supply the defi- 
ciency by artificial feeding. Children who are weaned should have plain 
but nutritious and easily digested diet, a part of which should be milk. 
If the predisposition to tuberculosis is strong, a little alcoholic stimulant 
may be allowed three or four times daily in the milk, though with the 
risk of creating an appetite for it. To an infant two or three drops of 
Bourbon whisky may be given for each month of its age, and to children 
of three to five years a teaspoonful. Kesidence in an airy and salubrious 
locality, outdoor exercise, a scrupulous avoidance of exposure by which 
a cold might be contracted, are necessary in order to the continued latency 
of the diathesis. Loss of flesh or appetite, or other evidences of failing 
health, indicate the need of additional measui-es of a therapeutic character. 
Iron, with cod-liver oil, citrate of iron and quinine, elixir of calisaya bark, 



136 SYPHILIS. 

or other touic, should be employed iu conuection with the alcoholic stimu- 
lant and suitable regimen. By the employment of such precautionary 
measures as soon as indicated, multitudes of children might be saved from 
tuberculosis who now perish. 

Curative. — The treatment of the general disease should be the same in 
children as in adults. The medicinal curative agents which are required 
in ordinary cases are cod-liver oil, iron, or other tonic, and an alcoholic 
stimulant given three or four times daily. The oil is less unpleasant and 
more readily taken when combined with the stimulant. An eligible mix- 
ture is equal parts of cod-liver oil and wine of iron, or cod-liver oil with 
half its quantity of Bourbon whisky, and a few drops of the tincture of 
chloride of iron. It should be given after nursing or the meals. At the 
age of one year two drops of the tincture of iron and a teaspoonful of 
cod-liver oil would constitute an ordinary dose. 

If the cod-liver oil is not tolerated, or if it impairs the appetite, it 
should be discontinued. In cases of diarrhoea it is of little or no benefit, 
and may do harm. Under such circumstances patients sometimes do 
better with simple regimenal measures, aided by alcoholic stimulants, and 
one of the least unpleasant of the tonics, as wine of iron or the calisaya 
bark. The regimen already recommended for prevention, is also required 
as a part of the curative treatment. 

Certain modifications of treatment are demanded on account of the 
localization of the tubercles. Intra-cranial tuberculosis, as soon as diag- 
nosticated, should be treated by pretty decided doses of iodide of potas- 
sium, though, unfortunately, there is little prospect of improvement. The 
glandular disease, whether bronchial or mesenteric, requires the iodide 
of iron, with or without that of potassium. Pneumonitis or pleuritis, so 
frequent a complication of pulmonary tuberculosis, requires emollient 
poultices, with moderate counter-irritation, and the judicious use of opi- 
ates with stimulants. The peritonitis occurring in abdominal tuberculosis, 
which is usually circumscribed, is best treated by fomentations and poul- 
tices, with opiates, and the diarrhoea by subnitrate of bismuth and chalk, 
five to ten grains of each, or the bismuth with Dover's powder ; or a more 
active astringent. 



CHAPTEK IV. 

SYPHILIS. 

Syphilis in infancy and childhood presents itself under two forms, 
namely, the congenital and acquired; the former is the more frequent. 
Etiology. — Congenital syphilis may be derived from either father or 



CLINICAL, HISTOEY. 137 

mother. Either parent, having previously had syphilis, may transmit it 
to the offspring, although at the time free from syphilitic symptoms. The 
mother, healthy at the time of conception, but infected with syphilis prior 
to the eighth month of gestation, may communicate the disease to the 
foetus ; syphilis contracted in the eighth or ninth month does not affect 
the foetus. If both parents have syphilis, the infant is almost necessarily 
syphilitic ; on the other hand, if only one parent is affected, the infant 
may or may not be contaminated. Sometimes, with such parentage, a 
part of the children are syphilitic, and a part healthy. 

Acquired syphilis in infancy and childhood may be received through 
primary lesions — that is, by reception of the virus from a chancre or bubo ; 
or it may be derived from certain of the secondary lesions. Inoculation 
by primary lesions may occur at the birth of the infant, from a syphilitic 
sore in the vagina or upon the vulva of the mother ; inoculation in this 
manner is, however, rare. Children may also receive the virus from pri- 
mary lesions on the persons of nurses or companions. Infection in this 
manner is sometimes accidental, and sometimes the result of criminal con- 
duct. A chanci-e on the breast of the wet-nurse not very infrequently 
communicates syphilis to the nursling. 

The contagiousness of " secondary manifestations," for a long time doubt- 
ed, is now fully established. Syphilis may be communicated by the secre- 
tion or exudation of a mucous patch, or a secondary sore. Hence the dan- 
ger of lactation by unhealthy wet-nurses, though they present no symptoms 
of recent syphilis. Excoriations or sores upon the nipple or breast of an 
infected wet-nurse may communicate the disease to the nursling ; and, on 
the other hand, mucous tubercles or fissures upon the lips or tongue of the 
infected infant may be the means of contaminating a healthy wet-nurse. 
Many such cases are now contained in the records of medicine. Vaccina- 
tion by means of the scab is also a mode by which constitutional syphilis 
may be communicated. For further particulars in reference to this sub- 
ject the reader is referred to our remarks on vaccination. 

Clinical History. — The effects of the syphilitic poison upon the de- 
velopment of the foetus, and the development and health of the infant, are 
different in different cases. The foetus, under the influence of the poison, 
often ceases to grow, shrivels, dies, and is expelled, long before term, or it 
may be born alive, but prematurely, and showing clear evidences of the 
disease, as soon as it comes into the world ; or, again, it may be born at 
term, but dead. So frequently is syphilis a cause of non-viability, that 
as Trousseau has remarked, this disease should be suspected as the cause, 
whenever a woman repeatedly aborts. Abortion from syphilis commonly 
occurs at or about the sixth month of gestation. In these cases in which 
the foetus dies from syphilis there is often placental syphilitic disease, 
namely, an undue growth of cells in the villi, which, compressing the ves- 
sels, give rise to fatty degeneration, and prevent the requisite interchange 



138 SYPHILIS. 

between the maternal and foetal blood. (Herring, Frankell.) Frankell 
designated the change " granulation-cell hypertrophy of the placental 
villi." Virchow, in one case, found a gummy tumor in the maternal por- 
tion of the placenta. 

When a foetus destroyed by syphilis is expelled, it is apt to present a 
macerated appearance, the cuticle being detached over large patches of 
surface, and in other parts raised in blebs, with a thin, puriform, and offen- 
sive fluid underneath ; the liver is occasionally indurated, and abscesses 
with spots of inflammation are sometimes observed in the thymus glands ; 
the amniotic fluid is offensive, turbid, and of a greenish or greenish-brown 
appearance. 

If the foetus, in which syphilitic manifestations have begun to occur, 
has reached a viable age, and is born alive, it is small and imperfectly 
developed, often shrivelled and senile in appearance. The skin looks un- 
healthy, and it may exhibit a distinct rash. Bouchut saw a seven and a 
half months' infant born alive, with an eruption of a copper color upon 
the legs and arms^ and ouyxis upon the fingers and toes. The buUse of 
pemphigus are also not infrequent upon the skin at birth, or they appear 
within a few days, two or three, after birth. The smallest are about the 
size of a split pea ; but many are considerably larger; the largest consist 
of two or more which have coalesced. They contain a thin, greenish, 
purulent matter, and appear most frequently upon the palms of the hands 
and soles of the feet, but also in severe cases upon the face and over the 
surface of the body. Recently I was enabled to diagnosticate syphilis in 
an infant within a day after birth, by its small size and feebleness, and 
the appearance of large blebs of pemphigus upon its hands, feet, fingers 
and toes, over which the skin soon broke, leaving troublesome and bleed- 
ing sores ; coryza commenced about the twelfth day. The parents seemed 
healthy, but I was enabled to trace the syphilitic taint to the mother. 
Non-syphilitic pemphigus, the result of cachexia, sometimes appears soon 
after birth, but its primary and usual seat is around the neck, and upon 
the body. I have known it to appear within the first week of life, and 
end fatally by the close of the second week. I have not found it diflScult 
to distinguish it from syphilitic pemphigus by the history of the family, 
and its absence from the palmar and plantar surfaces of the hands and feet. 
Condylomata, mucous patches, and stains of a copper color are the prin- 
cipal syphilitic affections, besides pemphigus, which have been observed at 
birth on the bodies of contaminated infants. It is stated that M. Cullerier, 
in ten years' attendance at the Hopital de Lon-aine, met only two cases of 
syphilitic manifestations at birth, and Victor de Meric only two cases in 
forty-six infants, who were affected with congenital syphilis (Bumstead) ; 
but in the practice of others a larger proportion have exhibited symptoms 
at birth. Ordinarily the period in which congenital syphilis is first re- 
vealed by symptoms is between the fifteenth and fortieth days. Rarely 



CLINICAL HISTORY. 139 

the manifestation of the disease is delayed several months. M. Diday ascer- 
tained the time of the commencement of symptoms in 158 cases, as 
follows : 



Before the completion o 


f one month after birth, in 


. 86 


a u 




two months " 


. 45 


u 




three " " 


. 15 


At four months, . 




. 


. f^ 7 


" five " 








" six " 




. 




" eight " 









" one year, 








" two years, 









In cases of tardy commencement of syphilitic symptoms it is probable 
that the poison has been partially eradicated from the affected parent by 
appropriate treatment. 

The nutrition of the infant who has inherited the syphilitic taint, but 
does not exhibit it at birth, is for a time good, but it begins to be im- 
paired when the local manifestations of syphilis appear, or soon after. The 
system gradually wastes ; the skin loses its fresh and healthy appearance, 
and becomes sallow, and, after a time, more or less wrinkled ; the features 
become pinched or contracted, and wear a sad expression. M. Diday says: 
" Next to this look of little old men, so common in new-born children 
doomed to syphilis, the most characteristic sign is the color of the skin." 
Trousseau thus describes this discoloration of the surface : " Before the 
health becomes affected, the child has already a peculiar appearance ; 
the skin, especially that of the face, loses its transparency ; it becomes 
dull, even when there is neither puffiness nor emaciation ; its rosy color 
disappears, and is replaced by a sooty tint, which resembles that of Asiatics. 
It is yellow, or like coffee mixed with milk, or looks as if it had been 
exposed to smoke ; it has an empyreumatic color, similar to that which 
exists on the fingers of persons who are in the habit of smoking cigarettes. 
It appears as if a layer of coloring had been laid on unequally ; it some- 
times occupies the whole of the skin, but is more marked in certain 
favorite spots, as the forehead, eyebrows, chin, nose, eyelids ; in short, the 
most prominent parts of the face ; the deeper parts, such as the internal 
angle of the orbit, the hollow of the cheek, and that which separates the 
lower lip from the chin, almost always remain free from it. Although the 
face is commonly the part most affected, the rest of the body always par- 
ticipates more or less in this tint. The child becomes pale and wan." 

The infant whose system is profoundly affected by syphilis rarely smiles, 
and its voice is feeble and plaintive ; its frequent wliimpcring cry is quite 
characteristic. 

CoRYZA is one of the earliest and most constant of the local affections 
which occur in infantile syphilis. It is slight at first, attracting little 



140 SYPHILIS. 

attention from the parents, who are not aware of its significance, and 
usually attribute it to a slight cold ; but it gradually increases. It gives 
rise to a secretion from the Schneiderian membrane, at first thin, but 
which becomes more consistent, and is attended by the formation of scabs. 
The thickening of the mucous membrane, in consequence of the inflam- 
mation and the presence of crusts, narrows the passage through the nostrils 
so as to produce snuffling respiration, and sometimes render nursing diffi- 
cult. In severe cases respiration through the nostrils is almost wholly 
prevented, so that death may occur from inanition, unless the breast is 
milked into the infant's mouth, or it is fed with a spoon ; but, ordinarily, 
even in grave coryza, it continues to nurse, though obliged often to release 
its hold of the nipple to obtain breath. It is when coryza begins to inter- 
fere with lactation that it first alarms the parents. The inflammation at 
the same time may affect the throat and larynx, causing hoarseness of the 
voice. Ulceration of the Schneiderian membrane and the subjacent car- 
tilage or bone is rare in infancy or childhood, although cases occur which 
are even attended with moi'e or less flattening of the nose. Diday believes 
that the discharge which accompanies coryza is in great part due to mucous 
patches developed on the Schneiderian membrane. The upper lip, over 
which the discharge flows, becomes red, excoriated, and more or less 
incrusted. The coryza, in most cases, coexists with other local syphilitic 
aflfections. Occasionally it occurs alone, and is the only evidence of the 
presence of the specific taint, except such as is afforded by the mal-nutri- 
tion and general appearance of the patient. 

Mucous PATCHES occur in most patients. They are developed either 
upon the mucous surfaces, or upon parts of the skin which are thin and 
exposed to friction, and such as are moistened by secretion or transudation 
from the vessels underneath. The most common seat of mucous patches 
is at the termination of mucous canals ; but in infancy, on account of the 
peculiar delicacy of the skin, they may occur upon almost any part of the 
cutaneous surface. They are most common, however, around the anus, 
upon the vulva, scrotum, umbilicus, labial commissures, in the axillse, and 
behind the ears. 

Mucous patches upon the skin present a rounded border, and are slightly 
elevated. Their color has been compared to that of the skin which has 
been softened by the prolonged application of a poultice. Erosions and 
cracks sometimes occur in the patches, from which a thin liquid exudes. 

Upon mucous surfaces they are less elevated than upon the skin, and 
are prone to ulcerate. These ulcerations, commencing at the centre, ex- 
tend, and soon the mucous patch disappears, and its site is occupied by an 
ulcer. The ulcer may be circular, oval, elliptical, crescentic, or irregular. 
The arches of the fauces are a common seat of mucous patches. 

Roseola is an occasional symptom of infantile syphilis. " It is distin- 
guished," says Diday, " by patches of a bright rose-color, circumscribed, 



VISCERAL LESIONS. 141 

irregularly rounded, of various sizes (most frequently about as large as 
one of the nails) ; appearing, by preference, on the belly, lower part of 
the chest, neck, and inner surface of the extremities." The spots do not 
readily and fully disappear by pressure. 

Pemphigus appearing soon after birth has already been alluded to. 
Its most frequent seat, whether occurring after birth or as a subsequent 
manifestation, is, as we have stated, the palms of the hands, soles of the 
feet, the fingers, and toes. This eruption commences by a violet tint of 
the skin, and in the course of twenty-four to forty-eight hours a watery 
fluid collects underneath, which soon becomes turbid. The skin peels oW, 
and sometimes an angry sore results, which bleeds readily when rubbed or 
pressed. In other and more favorable cases new skin takes the place of 
that which is lost. Pemphigus at birth is a precursor of death, but when 
it appears for the first time some weeks after birth, it is a less unfavorable 
prognostic. In cases of recovery it disappears, with proper treatment, in 
two or three weeks. 

Acne, impetigo, and ecthyma are occasionally observed in children 
afilicted with syphilis. The indurated pustules of acne occur most fre- 
quently upon the shoulders, back, chest, and buttocks. The pus is some- 
times absorbed, and in other cases discharged, leaving a small cicatrix, 
which, after a time, disappears. Impetigo appears most frequently upon 
the face, and occasionally upon the chest, neck, axilla, and groins. Un- 
like simple impetigo, the syphilitic impetiginous eruption is surrounded 
by a copper-colored areola. Ecthyma occurs upon the legs and buttocks 
chiefly. It commences as violet-colored spots, which are soon transformed 
into pustules. Ulcers succeed, w'hich, in reduced states of the system, are 
apt to enlarge and endanger the safety of' the child. Of the three pus- 
tular eru]Dtions, acne, according to Diday, is the least serious — indicating 
a " less confirmed diathesis." Ecthyma is the most serious, on account of 
the reduced state of system with which it is apt to be associated. Syphil- 
itic papulse and squamae are rare in infants, but cases have been observed. 
Onychia occasionally occurs, though less frequently than in syphilis of the 
adult. 

VisCKT^AL Lesions. — The visceral lesions which occur in the syphilis 
of infancy and childhood are, suppuration in the thymus gland ; gummy 
tumors in certain organs, most frequently the lungs and liver ; increase of 
the connective tissue of the livei', known as syphilitic cirrhosis ; partial 
perihepatitis, with depressions resembling cicatrices on the surface of the 
liver; peritonitis; periostitis, with thickening of the bone and exostosis. 

(Sup^iurative inflammation in the thymus gland is not common, or has 
not been frequently observed. When it is present the gland sometimes 
presents its normal appearance externally, and the abscess is only discov- 
ered by incisions. Gummy tumors are white and spheroidal ; some are as 
small or smaller than a pin's head, while others are as large as a pea, or 



142 SYPHILIS. 

even a hazel-nut. I have seen a considerable numbei' of them not as 
large as a pin's head, in the liver of an infant. Gummy tumors, accord- 
ing to Lebert, consist " of loose fibrous tissue, made up of pale elastic 
fibres, inclosing in their large interspaces a homogeneous granular sub- 
stance, the elements of which are less adherent to each other than in de- 
posits of true tubercle." Lebert also, with other microscopists, discovered 
round granular cells in these tumors. According to Robin, gummy tumors 
"are made up of rounded nuclei belonging to fibro-plastic cells, or cyto- 
blastions; of a finely granular, semi-transparent, and amorphous substance ; 
and, finally, of isolated fibres of cellular tissue, a small number of elastic 
fibres, and a few capillary bloodvessels." 

Constitutional syphilis is one of the principal causes of waxy degenera- 
tion, and the spleen and liver of infants may be enlarged from this cause. 
Dr. Samuel Gee has expressed the opinion that in half the cases of hered- 
itary syphilis the spleen is enlarged. (London Lancet, April 13th, 1867.) 

Infiltration of the liver by fibrous substance was first noticed by Giibler. 
It is not common in the infant. A specimen, showing this lesion, was pre- 
sented to the London Pathological Society in 1866, by Dr. Samuel Wilks. 
The following remarks by Dr. Wilks convey a good idea of the appearance 
and state of the liver in syphilitic cirrhosis: " Having dissected the bodies 
of several infants, who have died of congenital syphilis, I have found fatty 
livers, and an inflammation of the capsule ; but in only two have I dis- 
covered adventitious products of a fibrous character. The present exam- 
ple, however, corresponds in every particular with the disease described 
by Giibler. It must be distinguished (at least as far as the naked-eye ap- 
pearance reaches) from the syphilitic disease of adults, of which many 
specimens have been before the Society. In these the organ is cicatrized 
on the surface, and contains distinct nodules of fibrous tissue; whilst in 
the disease of children, as in the present specimen, the whole organ is in- 
filtrated by a new material, and it consequently becomes, as described by 
Giibler, hypertrophied, globular, and hard, resistant to pressure, and even 
when torn by the fingers, its surface receives no indentation from them ; it 
is also elastic, and when cut, creaks slightly under the scalpel. This was 
the form of disease in the present specimen. It came from a syphilitic 
child, a month old, in whom the liver could be felt enlarged during life, 
and when removed weighed a pound and a half. It was smooth on the 
surface, and so hard that it resembled rather a fibrous tumor than a liver." 
It is seen that the liver in the syphilitic child is liable to thi'ee distinct 
pathological processes, namely, gummy tumors, cirrhosis or fibroid de- 
generation, and waxy degeneration. 

Syphilitic perihepatitis and periostitis are more rare in infancy and 
childhood than in adult life, but they occasionally occur. The late Sir 
James G. Simpson considered peritonitis in the foetus one of the results of 
syphilis, and the cause of its death. 



OSSEOUS LESIONS. 



143 



Osseous Lesions. — "Within the last few years, imjDortant discoveries 
have been made in regard to the effect of syphilis upon the nutrition of the 
bones in children. In 1870, Dr. Wegner, of Berlin, published his observa- 
tions of the state of the skeleton in twelve syphilitic children, who were 
either stillborn, or who died within a few days or weeks after birth. He 
found clear proof that the syphilitic dyscrasia very frequently disturbs the 
nutrition and produces anatomical changes in the skeleton of the foetus. 
The following are the lesions, clearly referable to syphilis, which he ob- 
served : Periostitis of long bones, including the ribs ; softening, separation, 
and sometimes crepitation, at the point of union of diaphysis and epiphysis; 
chalky concretions and infiltrations along the line of ossification ; fatty 
degeneration of marrow; irregular formation and distribution of spongy 
substance in the epiphysis. These lesions were not all observed in each 
case, but they occurred with such frequency, that there could be no doubt 
that they were due to the specific taint of system. Confirmatory observa- 
tions also, in twelve cases, have since been made by Waldeyer and Kobner.^ 

Again, there is a syphilitic lesion of the bone in children, which is not 
usually present or has not usually been observed at birth, but is developed 
in the first weeks or months of infancy. The lesion alluded to is a cir- 
cumscribed enlargement of one or more bones. This has been most fre- 
quently observed upon the long bones, including the clavicle and ribs ; but 
in certain children it occurs upon other bones in addition. In some cases 
it is one of the first manifestations 
of hereditary syphilis, occurring even 



sooner than the coryza, while in 
others several months elapse before 
it appears. In one case, reported by 
Dr. Bulkley,'' of this city, it was 
first seen only a few days after birth, 
being perhaps congenital ; while in 
another case, in which the enlarge- 
ment was upon certain phalanges, 
and which is represented in the ac- 
companying figure, it appeared at 
the age of twelve months. When it 
occurs upon a phalangeal bone, it is 
designated dactylitis syphilitica. 

The enlai'gement, if upon a long 
bone, ordinarily begins at or near 
the point of union of the diaphysis 
with the epiphysis. It is located 



p\ 



(C^v 



^ 



1 See elaborate paper by K. W. Taylor, M.D., New York Journal of Obstetrics, 
etc., July, 1874. 

2 Eare cases of congenital syphilis, New York ]\[ecl. Journal, May, 1874. 



144 SYPHILIS. 

upon the extremity of the shaft which it encircles, and it extends over 
a part or nearly the whole of the epiphysis. It has an elevation of per- 
haps one-half or three-quarters of an inch in typical cases ; its surface is 
smooth, or slightly undulating, and the skin over it, though distended, 
has its normal appearance, and is easily movable, unless ulcerations have 
occurred. 

These enlargements, which result from the specific inflammation occur- 
ring in the periosteum and the bone, may resolve under proper treatment; 
but if neglected, and the anti-hygienic conditions are bad, degenerative 
changes may occur, ending in ulceration and destruction of the diseased 
part to a greater or less extent. 

Though these bone enlargements, whenever observed, should excite suspi- 
cious of syphilis as the cause, enlargements which present the same general 
appearance do occur from other causes. Such a case was observed by 
me in the children's class in the Outdoor Department of Bellevue, and 
Dr. Bulkley details another case in his paper. In the case observed by 
me, the inflammation and enlargement seemed to be strumous. Biiumler 
says : " Dactylitis, syphilitica does not always originate in the bone ; similar 
appearances may be produced through gummous formation in the sheaths 
of the tendons, and in the fibrous structure of the finger ;'' and again, "Its 
outward appearances may be produced also by tuberculosis, enchondroma, 
or sarcoma of the bone-marrow." (Art. Syphilis, Zleimsen's Encycl.) 

Mr. J. Hutchinson, of London, has called attention to the fact, that 
hereditary syphilis, having perhaps been manifested by the usual symptoms 
during infancy, and then becoming latent, may give rise to new symptoms 
after the fourth year. The most noticeable of these symptoms is a dwarf- 
ing of the permanent incisor teeth, which are rounded and peg-like, and 
their enamel notched at the free ends of the teeth. On account of the 
small size and shape of the teeth, there are 
inter>})aces between them. This abnormal 
development is most marked in the central 
inciisors of the upper jaw, and in certain 
ca-es it is limited to them, and it never ap- 
pears iQ the other incisors unless it does also 
in them. Another symptom, which only 
appears in hereditary syphilis, is an inter- 
stitial keratitis occurring on both sides, and attended by the deposition of 
fibrin in the substance of the cornea. In a few^ weeks the inflammation 
declines, but a slight opacity of the cornea remains. The cerebral nerves 
may become affected, usually a single pair — if the auditory, deafness re- 
sulting ; if the optic, dimness of sight. Occasionally there are other 
manifestations of syphilis in this period, as enlargement of spleen and 
liver, and nodes upon the long bones. 

Prognosis. — This depends in great part on the general condition of 




TREATMENT. 145 

the patient. If there is much emaciation, and the symptoms indicate a 
deeply seated cachexia, a considerable proportion perish. On the other 
hand, if the general health is not greatly impaired, although the local 
affections are pretty severe, the prognosis with correct treatment is good. 
The younger the infant, when the symptoms of syphilis appear, the more 
unfavorable, as a rule, is the prognosis. 

Treatment. — Parents who beget syphilitic childi-en ought, from a due 
regard for their offspring, to make use of antisyphilitic remedies, although 
they present in their persons no evidences of syphilitic taint. A good pre- 
scription for the parents is one-sixteenth of a grain of corrosive sublimate 
in the compound tincture of bark, given twice or three times daily for 
several weeks. If the father has had syphilis, both parents should be sub- 
jected to this treatment, and it may be continued, at least on the part of 
the mother, during the first months of her gestation. So small a dose of 
the mercurial does not, in my opinion, materially increase the liability to 
miscarry. There is much more danger of miscarrying from allowing the 
syphilitic taint to remain uncontrolled. Some prefer the use of mercurial 
ointment in the treatment of pregnant women for syphilis, in the belief 
that it is less likely to produce abortion. It is used for this purpose in the 
proportion of one drachm to the ounce. It is equally effectual in the erad- 
ication of the syphilitic taint with the small dose of corrosive sublimate 
recommended above for internal administration ; but it is impossible to 
determine the quantity of mercury which enters the circulation when in- 
unction is employed, and salivation is more likely to occur. 

Syphilis in the infant requires mercurial treatment as in the adult. 
Mercury may be employed internally or by inunction. Some prefer in- 
unction in the treatment of ordinary cases, in the manner recommended 
by Sir Benjamin Brodie. "I have spread," says he, "mercurial ointment, 
made in the proportion of a drachm to an ounce, over a flannel roller, 
and bound it round the child once a day. The child kicks about, and, 
the cuticle being thin, the mercury is absorbed. It does not either gripe 
or purge, nor does it make the gums sore, but it cures the disease. I have 
adopted this practice in a great many cases, with the most signal success." 
Trousseau, on the other hand, discountenances the use of inunction, as 
mercurial ointment applied to the skin produces irritation, and increases 
the suffering and restlessness of the child, fie prefers the following solu- 
tion, which is known as Van Swieten's, for internal treatment : 

R. Ilydrarg. bichlorid., 1 part; 
Aquae, 900 parts; 
Spts. rectific., 100 parts. Misce. 
Dose, one, or at most, two grammes (23 to 46 gr.) in milk, daily. 

As regards the choice between inunction and internal treatment, it may 
be said that the former is preferable in very reduced states of system, and 
in those who are affected with diarrhcea. The ointment should not be ap- 

10 



146 SYPHILIS. 

plied to much of the surface; two or three square inches are sufficient. To 
avoid inflaming the surface, the position of it may be varied from time to 
time, and it need not be continuously applied. In eases other than those 
excepted above, I prefer internal treatment. Van Swieten's liquid may 
be given, or one of the following formulae may be employed : 

R. Hj'drarg. cum creta, gr. iij-vj. 
Sacch. alb., 9j. Misce. 
Divid. in chart. No. xii. One powder 3 times daily. 
R. Hydrarg. chlor. corros., gr. j-ij. 
Syr. sarsae com p., gij. 
Aquse, 5viij. Misce. 
One teaspoonful 3 times daily. 

R. Hyd. "chlor. corros., gr. ss. 
Potas. iodid., ^j. 
Ferri et ammon citrat., ^j. 
Syr. simplic, ^vj. Misce. 
Dose, one teaspoonful 3 times daily for a child of 3 to 5 years. 
R. Hyd. chlor. corros., gr. j. 
Potas. iodid., ^ij. 
Sj-rup. simplic, 
Aqupe, aa ^ij. Misce. 
Dose, six drops 3 times daily for a child of 3 months. 

Mercury, in whatever way employed, should not be discontinued en- 
tirely till several weeks after the syj^hilitic symptoms have disappeared ; 
it is proper to continue it for a time, in diminished quantity, after the 
health seems fully restored. 

When the mercurial is omitted, tonics are often required. The prepa- 
rations of cinchona are useful in certain cases, as are also those of iron. 
If the patient remain feeble and pallid, presenting evidences of struma, 
cod-liver oil and syrup of the iodide of iron will be found beneficial con- 
tinued for some weeks or months after the mercurial is discontinued. At- 
tention should always be given to cleanliness and the hygienic manage- 
ment of the child. In some instances direct treatment of the local affec- 
tions is serviceable. To aid in the cure of syphilitic coryza, the following 
ointment should be applied within the nostrils by a nasal sponge three 

times daily. 

R. Ung. hydrarg. nitratis, ;5ij. 
Ung. zinci oxidi, gij. Misce. 

Condylomata or mucous patches seated upon the cutaneous surface may 
be dusted with calomel. At my clinique in April, 1871, a child two years 
and ten months old was presented, with a large condylomatous outgrowth 
near the anus. The history of the child showed that in all probability the 
disease had been contracted within a year from syphilitic children in one 
of the public institutions. Within three weeks this affection disappeared 
by dusting upon it calomel daily, with appropriate internal treatment. 



SECTION 11. 

EEUPTIYE FEVEES. 



CHAPTER I. 

MEASLES. 

The disease knowu in the vernacular as measles has also the names 
rubeola and morbilli. It is a common exanthematic affection, occurring 
at any age, but most frequently in childhood. It affects once the ma- 
jority of mankind. Writers recognize three stages of measles : first, that 
of invasion, which ends with the appearance of the eruption ; secondly, 
the eruptive stage ; and thirdly, the stage of decline or desquamation. 

Symptoms. — This disease commences with such symptoms as usually 
occur in mild but pretty general inflammation of the air-passages, namely, 
cough, fever, anorexia, and thirst. The eyes present a suffused, moderately 
injected, and brilliant appearance, and the buccal and faucial surface is 
injected. The Schneiderian membrane, and that lining the larynx, trachea, 
and bronchial tubes, participate in the increased vascularity. The cough 
at first is dry, and sometimes distinctly croupy. Catarrhal or false croup, 
indeed, is not infrequent in the initial period of measles. The cough is 
attended by little acceleration of respiration, and by little or no pain in 
the respiratory movements. If auscultation is practiced at this early stage, 
we observe the vesicular murmur, somewhat harsh in character, and some- 
times sonorous and sibilant rales. A little later, rales of a moist character 
appear. 

The patient, if old enough, commonly complains of headache, and of 
dull pain in the epigastric region or the centre of the sternum, due to the 
bronchitis. With these local symptoms febrile reaction occurs. The tem- 
perature rises to about 102° or 103°, as indicated by the thermometer in 
the axilla. The pulse numbers from 110 to 130 per minute. The fever 
is somewhat greater than in primary tracheo-bronchitis, except when the 
bronchitis becomes capillary, but it is less than in most cases of scarlet 
fever. 



148 MEASLES. 

The fever in the premonitory stage of measles after the first day is not 
uniform. It is attended by remissions and exacerbations, the former 
occurring in the first part of the day, the latter in the evening. Some- 
times two exacerbations occur in the day. The face is flushed and some- 
what swollen, especially during the times of increase in the fever, and the 
child is drowsy or restless. Vomiting, so common a symptom in the com- 
mencement of scarlet fever, occasionally occurs in measles. While in 
scarlet fever this takes place in the first twenty-four hours, in measles it 
occurs with about equal frequency at any period previously to the erup- 
tion. It was present during the first stage, sometimes almost as late as the 
eruptive period, in thirteen, and was absent in twenty-three cases, of which 
I have pi-eserved records. 

The duration of the first stage varies in different cases. It is usually 
from two to five days, with an average of about four. Occasionally it is 
more protracted on account of some disturbance in the economy, either 
from exposure to cold or other cause, which prevents the necessary afflux 
of blood towards the surface, and retards the eruption. In eighteen cases 
in my practice in which the duration of the cough previously to the 
appearance of rash was accurately ascertained, the time varied from one 
to five days, with an average of three and one-third ; in ten other cases it 
had continued, the parents stated, about a week, and in five, from one to 
two weeks, previously to the eruption. 

The eruption commences, when the disease pursues its normal course, 
upon the forehead and neck, then the face, and gradually extends down- 
wards, occupying from twenty-four to thirty-six hours in passing over the 
trunk and limbs. It appears first as indistinct red points, not more than 
a line in diameter, which increase in size and become more distinct. Their 
borders ax-e uneven or irregular, or they are finely notched ; their general 
shape is, however, circular, except as two or more unite, when they may 
assume any form. The crescentic form which writers describe is due to 
the union of two points of eruption. The largest of these spots, when 
there is no coalescence, do not exceed a quarter of an inch in diameter, 
and many are much smaller. Frequently in plethoric children, if there 
is much fever, there is continuous redness over several inches of surface. 
The eruption is then confluent. This form is often observed upon parts 
of the surface where the capillary circulation is most active, w^hen it is 
discrete elsewhere. In some of these cases, diagnosis of measles from 
scarlet fever is attended with difficulty. 

The rubeolous eruption is slightly elevated. This is not appreciable to 
the sight, but can be ascertained by passing the finger slowly over the 
skin, when a little roughness is felt at the point of eruption. Sometimes 
the elevation, especially in the commencement of the efflorescence, is not 
appreciable, even to the touch. The eruption is broad and flat, never acu- 
minate, never changing its form to the vesicular or pustular. It disappears 



SYMPTOMS. 149 

by pressure, and immediately reappears when the pressure is removed. It 
has been compared in appearance to flea-bites. Small, pointed, papular, 
vesicular, or pustular eruptious are sometimes seen in connection with 
those of measles, but they are accidental, occurring in other states of sys- 
tem as well as in measles, if there is the same augmented temperature. 

In the commencement of the eruptive jDeriod the severity of the consti- 
tutional and local symptoms increases. The pulse and temperature cor- 
respond with the character which they presented during the exacerbations 
of the first stage. The features are slightly swollen ; the eyes still watery 
and sensitive to light ; the conjunctiva, ocular and palpebral, and the 
mucous membrane of the cavity of the mouth and of the air-passages, 
continue injected. The tongue is covered with a moist thin fur, and its 
papillse are prominent, though less so than in scarlet fever. The cough 
"continues frequent, and is seldom attended with much expectoration, in 
uncomplicated cases ; often there is no expectoration whatever. The ap- 
petite is lost, but drinks are readily taken on account of the thirst. Diar- 
rhoea sometimes occurs on the first day of the eruption, but it lasts only 
a few hours, and, if the disease pursues its usual course, abates of itself. 
With the exception of this the bowels are regular, or a little constipated 
during the eruptive period. 

On the second day of the eruption, or sixth of the fever, the symptoms 
begin to abate. The pulse is less accelerated, and the temperature dimin- 
ishes ; the cough is less frequent and is easier, and the flushed and swollen 
appearance of the face declines. By the close of the third or on the 
fourth day the rash has disappeared in the order in which it extended 
over the body. There only remain faint maculse, which in the course of 
a day or two fade completely. 

With the disappearance of the rash the fever nearly or quite ceases, but 
a slight and painless cough continues for several days. 

Occasionally the eruption presents a livid appearance ; this is the rube- 
ola nigra of writers. From cases which I have observed, it is my opinion 
that this should not be considered a distinct sj)ecies in the vast majority 
of cases, but that the dark color is due to internal inflammation, usually 
capillary bronchitis or pneumonia, which prevents full oxygenation of the 
blood. Rarely rubeola nigra is due to the vitiated state of the blood, or 
the malignant nature of the disease. The course of the eruption in this 
form of measles is somewhat different; it continues longer, fades more 
slowly, and does not disappear so readily on pressure. Traces of it are 
observed a week or more after its first appearauce ; it is apt to be fatal. 
Measles may present this form from the beginning, or, commencing as 
vulgaris, it may pass into rubeola nigra. 

Measles may be irregular in form, but aberrations arc less frequent than 
in scarlet fever. Writers describe measles without catarrh, and, on the 
other hand, with catarrh but without the rash. But positive diagnosis iu 



150 MEASLES. 

such cases must be difficult. It is probable that simple catarrh and roseola 
have sometimes been mistaken for the two forms of irregularity mentioned, 
but when a child, in a family of children affected with measles, presents 
all the symptoms of that disease, except the catarrh or except the erup- 
tion, the diagnosis of irregular measles would, as a rule, be correct. 

Occasionally the stage of invasion is very short, or even absent. In 
one case the parents informed me that the catarrhal symptoms began on 
the day when the eruption appeared. Convulsions sometimes occur at 
the commencement of measles, as well as during its progress. A single 
convulsive attack at the commencement of measles is usually not danger- 
ous; when repeated, it is more serious; it is also more serious'when it oc- 
curs in the course of measles. In certain cases the eruption appears in 
an irregular and partial manner, occurring, perhaps, at a late period, and 
indistinctly, upon the trunk alone, or upon the trunk and partially upon" 
the legs. In many cases of deferred or partial eruption there is internal 
congestion or inflammation of some part, which causes withdrawal of 
blood from the surface, and thus prevents the normal development of the 
rash. 

When the eruption disappears the third stage commences, that of des- 
quamation. It is characterized by a scanty furfuraceous exfoliation of 
the epidermis. The desquamation is seldom as great as in scarlet fever, 
and it occurs most where the eruption has been thickest and the epidermis 
most inflamed. Exfoliation occurs between the fourth and seventh days 
after the commencement of the eruption, the eighth and eleventh of the 
disease. In some children it does not take place, or is so slight as not to 
be observed. 

With the disappearance of the rash, the symptoms rapidly abate. The 
pulse becomes more natural, the temperature is reduced, the digestive or- 
gans return to their normal state, and convalescence is established. The 
cough continues several days after the other symptoms abate, but it is less 
and less frequent, and is not painful. 

Complications. — The complications of this disease are important. 
Much of the success of the physician in the management of measles de- 
pends on a correct diagnosis and understanding of them. The most fre- 
quent of these complications are bronchitis and broncho-pneumonia. 
Slight bronchitis is common in measles, but if it increase so as to cause 
embarrassment of respiration, and become a source of danger, it is prop- 
erly a complication. This complication, as well as j^neumonia, may occur 
at any period of measles, but it commences most frequently in the first 
stage. Occurring in the first stage, it may prevent the regular appearance 
of the rash ; if in the second, it often causes retrocession of it. 

When bronchitis becomes really serious, it usually has invaded the 
minute bronchial tubes. This disease, designated capillary bronchitis or 
suffocative catarrh, I have elsewhere described. The clinical history of 



COMPLICATIONS. 151 

fatal bronchitis, as a complication of measles, is as follows : The respira- 
tion, at first not notably altered, becomes, by degrees, accelerated, and the 
patient more and more fretful. The pulse, instead of becoming less ac- 
celerated, as after the first days of simple measles, is daily more rapid, and 
the respiration more frequent and labored. The dyspnoea gradually in- 
creases, the infra-mammary region is depressed during each inspiration, 
and the subcrepitant rale is heard on both sides of the chest. There is, 
probably, collapse or inflammation of some of the lobules. Finally the 
prolabia and fingers become livid, and death occurs from apnoea. Capil- 
lary bronchitis is diagnosticated from pneumonitis by the physical signs. 
It is in the young child more dangerous than that disease, unless per- 
chance the latter be double. A large majority of those affected under the 
age of three years, die. The anatomical characters of fatal bronchitis 
occurring in connection with measles, I have had an opportunity to in- 
spect. In an infant who died with this complication in the Infants' Hos- 
pital in the spring of 1867, there were evidences of continuous inflamma- 
tion from the epiglottis to the minutest bronchial tubes. 

Pneumonia as a complication does not diflfer materially from the idio- 
pathic form, except that it is more protracted and fatal. Its form is in 
most cases catarrhal, resulting from an extension of the bronchial inflam- 
mation. 

The next most frequent serious complication of measles is entero-colitis. 
This may commence at any period during the course of the disease. If the 
colon is more especially the seat of inflammation, the evacuations contain 
mucus and blood, unless in young children, in whom the stools, even in 
severe colitis, commonly have a green color. The anatomical character of 
this complication varies in different cases, like the idiopathic form of in- 
flammation. Sometimes there is simple arborescence of the intestinal 
mucous membrane, with tumefaction of its follicles; in other cases, in ad- 
dition to increased vascularity, the mucous coat is softened and thickened; 
and in others still, especially if the inflammatory action has been some- 
what protracted, ulceration occurs, for the most part in the site of the.soli- 
tary glands. Exceptionally, in fatal cases of measles attended with diar- 
rhoea, no vascularity is observed after death, although the intestine may 
be somewhat thickened and softened. In these cases the diarrhoea may 
have been non-inflammatory or inflammatory, the injection of the vessels 
having disappeared after death. 

Severe and obstinate diarrhoeal affections occurring with measles, usually 
commence as the primary disease is about declining. They then become 
sequelae, ending fatally in many instances several days or perhaps weeks 
after the disappearance of the eruption. Diarrhoeal attacks, occurring in, 
or previously to, the eruptive stage, are, as a rule, mild and easily relieved. 

In some grave cases, measles have a tendency from the first to affect the 
internal organs more than the surface. There then coexist bronchitis. 



152 MEASLES. 

pneumonia, and entero-colitis, with indistinctness of the eruption on the 
skin. Such complications render a fatal result highly probable. 

Another very fatal complication and sequel is true croup, commencing 
when rubeola is beginning to decline ; but it is less frequent than pneu- 
monia or entero-colitis. In catarrhal or false croup, which, as has been 
previously stated, is not infrequent at the commencement of measles, the 
cough has a loud, ringing character. In true croup, on the other hand, it 
is hoarse or harsh, and less distinct, on account of the presence of the 
pseudo-membrane in the larynx. True croup, always a grave disease, is 
more serious when it occurs as a complication of measles than in the idio- 
pathic form, not only because the blood is vitiated and the system reduced 
by the primary affection, but because the inflammation of the mucous sur- 
face is in general more extensive, as is also, I believe, the pseudo-mem- 
brane. This membrane in the croup of measles I have seen extend so 
far down the air-passages, that tracheotomy could not have been attended 
by any decided amelioration of symptoms. This complication, though 
always grave, is not, however, necessarily fatal. I have known cases re- 
cover by ordinary treatment, when for days there had been dyspnoea and 
other evidences of a pretty firm pseudo-membrane. True croup causes 
continuation of the fever, which had perhaps begun to abate. 

Diphtheria, when epidemic, also frequently complicates measles. Much 
of the mortality from measles in this city, since the year 1858, was due 
to this cause. In cases observed by myself, diphtheria usually began 
while the fauces were still inflamed, and sometimes before the eruption 
had begun to fade. 

These are the most common complications of measles. There are others 
of less frequent occurrence, among which may be mentioned congestion of 
the brain, with or without serous eff'usion. Stomatitis, pharyngitis, and 
otitis are occasional complications. Rarely, also, purpura, attended by 
haemorrhages from the different mucous surfaces, occurs in connection with 
measles. This complication is, however, more frequent in certain other 
constitutional diseases, as scarlet fever, and especially variola. 

It is seen that the inflammations which are apt to occur in the course 
of measles are chiefly of the mucous surfaces. In scarlet fever, on the 
other hand, the inflammations are more frequently serous. 

There are other affections, originating in measles, which are rather 
sequelae than complications. Gangrene of the mouth is one which, as 
stated in another part of the work, is more apt to occur after measles than 
any other disease. After a severe epidemic of measles in the Catholic 
Foundling Asylum, in 1874, three cases of gangrenous vulvitis occurred 
in those who had been affected. Ophthalmia commencing in measles often 
persists for weeks or months. It may give rise to granulation of the 
lids, and cases have been reported of violent inflammation of a purulent 
character, producing ulceration of the cornea, and destroying vision. The 



NATURE DIAGNOSIS. 153 

ophthalmia is sometimes very intractable. Inflammation of the Schnei- 
derian membrane, commonly present during measles, sometimes continues 
as a sequel, extending back as far as the Eustachian tube, where it may 
cause swelling, with impairment of hearing, and forward to the lip, where 
it may produce chronic eczema. 

Anatomical Characters. — I have made, or witnessed, according to 
remembrance, some six post-mortem examinations of those who have died 
in, or immediately after, an attack of measles. In all there were lesions 
due to complications. Indeed, death directly from measles is so rare that 
few have had an opportunity of studying the anatomical characters which 
are peculiar to this affection. In those who have died without any obvi- 
ous coexisting disease, and these cases chiefly occur in the malignant form, 
there has been congestion of the internal organs, especially marked in the 
lungs, and sometimes the tissues appeared softened. The blood, also in 
the malignant form, has a darker hue than natural, and ecchymotic patches 
have been observed upon the mucous surfaces and elsewhere, corresponding 
in character with the petechise under the skin which sometimes occur in 
this form of measles. In cases resulting fatally from bronchitis or pneu- 
monia the bronchial glands are commonly tumefied in the same manner 
as the mesenteric glands are enlarged in enteritis, and the glands of the 
mesocolon in dysentery. 

Nature. — Rubeola, like the other exanthematic fevers, is due to a ma- 
teries morbi, the exact nature of which is unknown. It is both inoculable 
and infectious. It has been inoculated by the serum from vesicles which 
sometimes occur in connection with the rubeolous eruption, and also by 
the blood from a patient. Inoculation does not appear to moderate the 
disease, and as measles, when contracted in the ordinary way, is not in 
itself dangerous, but dangerous only from complications, inoculation is 
not performed, except as a matter of scientific interest. The usual mode 
of propagation is by infection. It is communicated both by the breath 
and clothing. By fomites the virus is sometimes conveyed a long distance. 
The question is still undecided whether rubeola does not sometimes occur 
spontaneously. I have met cases, and have been informed of others, one 
especially, occurring in a sparsely settled portion of the country, in which 
there was apparently no exposure, and I incline to the opinion that its 
origin de novo is possible, though not frequent. 

Twelve to fourteen days elapse from the time of infection to the com- 
mencement of the eruption. In cases observed in the children's depart- 
ment of Charity Hospital, this period was ascertained to be about twelve 
days. In those who have been inoculated, the incubative jjeriod is said 
to have been about one week. Rubeola prevails epidemically, like the 
whole class of infectious diseases, and in different epidemics the type 
varies somewhat, as well as the character of the complications. 

Diagnosis. — The diagnosis of measles, previously to the eruption, is 



154 MEASLES. 

often difficult. The catarrhal symptoms then predominate, and these are 
such as may occur independently of any constitutional or blood disease. 
The first stage, therefore, of measles, is often mistaken for coryza, or mild 
bronchitis. The points of differential diagnosis are the suffused appear- 
ance of the eyes, the greater degree of fever on the first day than would 
be likely to arise from so moderate an amount of local disease, and on 
subsequent days remission and exacerbation of the fever. Measles in the 
first stage has been mistaken for remittent fever. The catarrhal symp- 
toms should prevent such an error. 

Sometimes roseola closely resembles measles in appearance, but the rash 
of roseola appears within a few hours after the commencement of febrile 
symptoms, and almost simultaneously over the whole body, and without 
those local symptoms referable to the mucous surfaces, which characterize 
measles. 

Variola on the first day of the eruption has sometimes been diagnosti- 
cated as measles. I recollect once being called to an infant with fatal 
confluent small-pox, who was said to have measles. A physician, a few 
days previously, observing the red points in the commencement of the 
eruption, had made this absurd diagnosis, and, predicting a favorable 
result, had not thought it necessary to repeat his visit. In case of doubt, 
it is the part of prudence to defer making a positive diagnosis. A few 
hours suffice to show the distinctive characters of the rubeolousaud vario- 
lous eruptions. But the anxiety of friends often necessitates the expres- 
sion of an opinion. The absence of catarrhal symptoms, the earlier 
appearance of the eruption, and its papular feel under the finger in small- 
pox, enable us to discriminate between the two diseases in the commence- 
ment of the eruptive stage. Moreover, the symptoms in the initial periods 
are different, as will be seen in our description of small-pox. 

Prognosis. — This is favorable, provided that there is no serious com- 
plication. With internal inflammatory complication, on the other hand, 
the disease becomes much more grave. A large pi'oportion thus affected 
die. The prognosis is also less favorable in feeble children with scanty 
eruption, or an eruption appearing at a late period and irregularly. 
Dyspnoea, persistent and great acceleration of pulse, and coma, indicate 
an unfavorable ending. Convulsions occur much more rarely in the 
course of measles than in scarlet fever, and when they occur after the 
initial period they usually end in coma and death. 

Treatment. — Uncomplicated measles require no medicinal treatment 
except to palliate symptoms. The child should be kept in an airy apart- 
ment, at a uniform temperature of about 70°. A temperature so elevated 
as to be uncomfortable to the nurse is injurious to the patient. But while 
the popular idea is erroneous, that he should be kept in a heated at- 
mosphere, it is correct that currents of air and sudden reduction of tem- 
perature are dangerous. A violent and fatal attack of croup occurred in 



TREATMENT. 155 

my practice in a girl of fifteen, in consequence of exposure at an open 
window during the period of desquamation. The diet should be mild, and 
for the most part liquid. The patient, indeed, refuses solid food, but, on 
account of the thirst, takes liquids more readily. Farinaceous substances, 
with milk, afford sufficient nutriment in ordinary cases. If the previous 
health has been poor and the vital powers reduced, or if there is a com- 
plication, more sustaining diet is required. Stimulation by wine or brandy 
is needed in these cases. During the two or three weeks succeeding an 
attack of measles, care should be taken to avoid exposure to cold, or 
changes of temperature, since during this period mucous inflammations 
are so apt to occur. 

The cough ordinarily requires treatment, inasmuch as the suffering of 
the child and loss of sleep are largely due to this symptom. Demul- 
cent drinks, as flaxseed tea, infusion of slippery-elm bark, or solution of 
gum Arabic, are useful, to which, to render them more palatable, lemon- 
juice may be added. A small Dover's powder, or the following mixture 
given occasionally, relieves the severity and diminishes the frequency of 
the cough : 

R. Tinet. opii camphorat , 

Syr. scillfe, 

Syr. Ipecac, aa ^ss.; 

Spts. ffither. nitr., ^ij. Misce. 
Dose, one teaspoonful to a child of five years, repeated according to circum- 
stances. 

As the chief danger in measles is from inflammation of the respiratory 
organs, local treatment dii-ected to the chest is important. The chest 
should be covered with oil silk, unless in the mildest cases. This increases 
the amount of eruption upon the surface underneath, and, I believe, tends 
greatly to prevent complication by bronchitis and pneumonia. If the 
eruption is tardy in its appearance, or indistinct, it is well to produce 
moderate counter-irritation by some gentle irritant underneath, as com- 
phorated oil, to which one-third part of turpentine is added. 

Affections which complicate measles should receive, for the most part, 
such treatment as is appropriate for them when idiopathic. Secondary 
diseases, however, require sustaining measures more than primary. In 
bronchial and pulmonary inflammations, which, if they occur early in 
measles, prevent the regular appearance of the eruption, or, if in the 
eruptive stage, cause its disappearance, pi-ompt counter-irritation over the 
chest by sinapisms, or otherwise, is required. Trousseau states that he has 
derived benefit in these cases, from what he designates urtication. This 
is produced by stroking the chest two or three times daily witli the nettle 
(urtica dioica or urtica urensj. This causes a prompt and abundant erup- 
tion, and with a less amount of suffering than one would suppose. The 
fever abates, and the respiration becomes more natural in proportion to 



156 SCARLET FEVER. 

the amount of uettlerasb. On the second day the effect is less than on 
the first, and after three or four days, says Trousseau, no further irritation 
results from the nettle. When counter-irritation is produced, by what- 
ever method, the chest should be covered with a warm and soft poultice, 
as the ground flaxseed ; derivatives to the extremities are useful in such 
cases. In capillary bronchitis and pneumonia stimulating expectorants 
are required, as carbonate of ammonia. 

The following I employ for a child of two to three years. 

R. Tine, ipecac, comp , 

(Squibb's liq. Dover's piilv.), gtt. viij-xvj. 

Ammon. carbonat., gr. xvj. 

Syr. bal. tolut., 

Aqiiffi, aa5J. ]Mi:5cc. 
One teaspoonful ever}' 2 or 3 hours. 

The cases of gangrenous vulvitis alluded to above were treated with a 
flaxseed poultice, and iodoform dusted over the surface each day or second 
day, with a satisfactory result. As regards the treatment of other compli- 
cations, the appropriate measures are detailed elsewhere. 



CHAPTER 11. 

SCARLET FEVER. 

The terms scarlet fever, scarlet rash, and scarlatina are identical. They 
are employed to designate one of the most frequent and fatal of the con- 
tagious diseases, a disease which may occur at any age, but is most com- 
mon in childhood, an exanthem attended with more or less pharyngitis. 
In this city, on account of its great frequency, and its large percentage of 
fatal cases, it causes more deaths than any other contagious affection. 
Though not more common than measles, it is attended, with us, by more 
than double its mortality. 

There is no disease that presents a greater difference, as regards char- 
acter and severity of symptoms, than scarlet fever, and this has led to the 
recognition of different forms of it. Rilliet and Barthez describe two, the 
normal and abnormal ; Meigs two, the mild and grave ; and most other 
writers, three or more. I shall, for convenience, follow Bouchut, who 
makes three varieties, namely, the regular, irregular, and malignant. 

Symptoms. Regular Form. — Scarlet fever usually begins abruptly. It 
is possible, often, to tell the exact time of its commencement. If there are 
any premonitory symptoms, they are ordinarily slight, so as scarcely to at- 



SYMPTOMS. 157 

tract atteotion, amounting to little more than dulness, or the appearance 
of fatigue. In some the first symptom is chilliness, and occasionally a dis- 
tinct chill is experienced. This is the ordinary mode of commencement in 
the adult. With or without the chilliness, fever, usually intense, arises, 
accompanied by such symptoms as ordinarily occur in a febrile state of 
system, such as cephalalgia, perhaps delirium, anorexia, thirst. The pulse 
rises to 110, 120, or more, per minute; the skin is hot, face flushed, the 
eyes bright, and occasionally more or less suffused. In many, there is sud- 
den starting or twitching, with a degree of stupor, showing that the cere- 
bro-spinal system is profoundly affected. 

In most cases there occurs within the first twenty-four hours a symptom 
which has considerable diagnostic value, namely, vomiting. In 117 cases 
in which I have recorded its presence or absence, it occurred in 90, usually 
not at the very commencement, but within the first twelve or eighteen 
hours. It commonly occurred before the appearance of the rash, but not 
always. In a few of the cases it is recorded as a symptom of the second 
day. Vomiting at this period is, probably, in most cases, sympathetic, due 
to the effect of the specific virus of the disease on the brain. It is not a 
severe symptom, occurring in most patients but once or twice. Great and 
persistent irritability of stomach indicates a serious form of scarlet fever, 
and is, therefore, prognostic of an unfavorable ending. When this symp- 
tom is absent or slight, or there is merely nausea, I have found the case 
ordinarily mild, so that, as regards the frequency of vomiting, the statis- 
tics of different epidemics vary according to the mildness or gravity of the 
type. The bowels are regular or somewhat constipated in this form of 
scarlet fever, or if diarrhoea occur, it is slight and transient. 

When the symptoms described above have continued six to eighteen 
hours, the rash appeal's. It is first observed about the ears, neck, and 
shoulders, in reddish indistinct patches, fading into the normal hue. These 
patches extend and unite, and in the course of a few hours the trunk and 
upper extremities, and finally the legs, are covered. The scarlatinous rash 
bears considerable resemblance to that produced by external heat or the 
redness from a sinapism, but there are numerous minute points of a deeper 
or duskier red than the surface generally. On passing the finger over the 
eruption, no distinct prominences are observed, but a sensation of rough- 
ness is sometimes imparted from engorgement of the cutaneous papillae. 
The rash disappears by pressure, but in robust children, and in favorable 
cases, it immediately returns when the pressure is removed. Slow return 
of the rash is evidence of sluggish circulation, and, when marked, it indi- 
cates the malignant form of the disease. The rash gives rise to an itching 
or burning sensation, which adds greatly to the discomfort of the patient. 
The degree of redness is not uniform over the surface, and sometimes, 
especially in mild cases, it is absent in places. 

Early in the disease, even before the cutaneous eruption, the buccal 



158 SCARLET FEVER. 

and faucial mucous membrane presents a pretty general red appearance, 
and the papilke of the tongue are elevated. Pharyngitis has already 
commenced, with more or less stomatitis and tonsillitis. The inflamma- 
tion renders deglutition painful, so that difficulty is often experienced in 
giving the necessary drinks. This state of the buccal and faucial mem- 
brane continues through the disease. There is sometimes a slight fibrinous 
exudation over the tonsils ; the tongue is covered with a moist fur, and the 
secretion from the follicles of the inflamed surface is increased and muco- 
purulent. The Schneiderian membrane also participates in the inflam- 
mation, and, as the disease advances, a thin, irritating discharge, containing 
pus-cells, flows from the nostrils. 

The temperature in the first days of scarlet fever is ordinarily from 102° 
to 105°, in grave cases even 105° to 107°. The cutaneous transpiration 
during this period is nearly checked, so that the skin is hot and dry. The 
respiration is moderately accelerated, but not so as to attract attention, 
unless there is a complication ; often there iS slight cough from mucus in 
the throat or bronchial tubes. Bronchitis, common in measles, and giving 
rise to prominent symptoms in that disease, is either absent or slight in 
scarlet fever. 

The symptoms pertaining to the digestive system during the initial 
period of scarlet fever have been sufficiently described. The subsequent 
symptoms do not differ materially in regular scarlet fever, except that 
there is no vomiting. The lips are dry and often cracked. The inflam- 
mation of the mouth and throat continues unabated, with anorexia and 
thirst. The urine is high-colored, and in robust children, during the first 
days of scarlet fever, it frequently deposits the urates on cooling. 

The symptoms continue with undiminished intensity for a period of from 
four to six days, when the fever begins to abate, the pungent heat becomes 
less, and the rash fainter. There is a gradual decline of the disease, which, 
in its inception, was so abrupt. In mild, and even pretty severe cases, 
which pursue a regular and favorable course, convalescence commences 
by the close of the first or beginning of the second week. In the second 
week, the rash, becoming less and less distinct, finally disappears, as do 
also the redness and swelling of the buccal and faucial surfaces. The 
engorgement of the papilli* of the tongue and that of the tonsils subsides ; 
the appetite returns; the countenance brightens and becomes natural, and 
the child who, during the height of the fever, scarcely noticed objects, or 
noticed them with indifference, or even repugnance, can be amused as 
before his sickness. 

The period of desquamation succeeds. Exfoliation of the epidermis 
occurs over the whole body. This commences about the face and neck, 
and it occupies several days, during which there is progressive improve- 
ment in the condition of the child. Where the skin is thin, the epidermis, 
as it is detached, presents a furfuraceous appearance ; where it is thick, as 



SYMPTOMS. 159 

upon the palms of the hands and soles of the feet, it separates in a layer 
of considerable thickness. 

Such is a brief account of scarlet fever, when it pursues its normal 
course, without complication or sequelee. But there is no disease which 
has so many unfavorable complications and sequelae as this. The liability 
to these renders the prognosis in all cases doubtful, and in many instances 
they are the immediate cause of death. They occur both in mild and 
severe cases of scarlet fever. 

The great diiference in different cases of scarlet fever, as regards inten- 
sity of symptoms, is well known. It is sometimes so mild, its character- 
istic features so slight, that diagnosis is necessarily uncertain. Examples 
in corroboration of this statement are not infrequent. In the spring of 
1866 I was called to an infant thirteen months old, who had slight pharyn- 
gitis, and an indistinct rash over a part of the surface. In two days the 
eruption had disappeared, and soon after the health was apparently fully 
restored. Diagnosis would have remained doubtful, except for sequelae. 
In another instance, two children passed through the entire course of 
scarlet fever, playing every day in the street. Although the intelligent 
grandmother saw the rash upon them, its nature was not suspected till 
nearly two weeks afterwards, when one was taken with fatal nephritis and 
general anasarca. In cases so mild as these, the heat of surface is not 
greatly increased, nor is the pulse much accelerated. There is no restless- 
ness, nor is the digestive function materially impaired. The rash does not 
have so deep a color, nor is it so continuous over the surface, as in cases 
of ordinary gravity. The patient begins to improve in from two to four 
days, and is soon well. So mild a form of scarlet fever is, however, quite 
exceptional, but there are all gradations, from this mildness to that malig- 
nant form which I shall presently describe. 

There is usually considerable faucial inflammation, even when scarlet 
fever pursues a regular and favorable course. If the pharyngitis is 
intense and protracted, many writers designate the disease scarlatina 
anginosa. There is, in these cases, not only general and pretty severe 
inflammation of the mucous membrane of the fauces, with swelling of 
the tonsils, and submucous infiltration, but also more or less tumefaction 
around the angle of the jaw, due to extension of the inflammation to the 
lymphatic glands, and connective tissue of the neck. In these cases the 
suffering of the patient is greatly increased by the amount of local disease. 
The adenitis and cellulitis, unless slight, do not subside with the disap- 
pearance of the rash, or they subside more slowly. They render the 
febrile movement more protracted. The swelling due to these inflamma- 
tions often continues one or two weeks after the disappearance of the 
rash, or even longer, when it disappears by resolution, or more I'arely by 
suppuration, the abscess opening externally. 

Irregular Form. — The irregular form of scarlet fever is commonly due 



160 SCARLET FEVER. 

to some perturbating cause. This cause is often a pre-existing or coexisting 
disease, or, if not actual disease, at least disordered state of system. For 
example, a little girl, in my practice, had the symptoms of scarlet fever, 
such as febrile movement and inflammation of the buccal and fuucial sur- 
face, nearly a week before the scarlatinous eruption appeared. During 
this period there were symptoms of enteritis, which declined when the 
rash occurred. The abdominal affection was the apparent cause of the 
irregularity in the malady. If scarlet fever occurs during an attack of 
eutero-colitis, there is frequently no eruption. Most practitioners have 
met cases like the following, which I now recall to mind : In a family 
where scarlet fever was prevailing, a little child, early after the com- 
mencement of symptoms which seemed to be plainly referable to the ex- 
anthematic affection, was seized with vomiting and purging, and the latter 
continued two or perhaps three days, when death occurred. There were 
the symptoms and appearances of severe scarlet fever, but without the 
eruption. In another instance, an infant in the warm months having 
protracted entero-colitis, the usual summer epidemic of this city, was ap- 
parently affected with scarlet fever, which was present in the family. 
There were the characteristic symptoms, but the diarrhoea continued, and 
there was no rash. 

In those that are much reduced by any antecedent disease, as phthisis, 
or that have a disease, chronic or acute, which produces a decided afflux 
of blood towards an internal organ, the eruption is commonly tardy in its 
appearance, indistinct, or wholly absent. The diseases which most fre- 
quently render scarlet fever irregular are those of an inflammatory nature. 
Some affections, occurring in connection with scarlet fever, do not change 
its symptoms, but themselves undergo modification. Scarlet fever occur- 
ring in a child having pertussis does not itself undergo any material 
change. The cough, not the fever, is modified (rendered milder) during 
the coexistence of the two. 

Scarlet fever may also be irregular in those that are robust and free 
from any other disease, assuming this form without any appreciable per- 
turbating cause. In 1867 I attended a young lady, whose previous health 
was excellent, and whose brother was sick at the time with scarlet fever. 
This patient had considerable fever, with pretty severe pharyngitis, and, 
though her surface was repeatedly examined, no eruption could be discov- 
ered. Two weeks subsequently she became affected with severe nephritis, 
anasarca, effiision into at least one of the pleural cavities, and probably 
into the pericardium, the case ending fatally. 

Eilliet and Barthez mention the irregular and incomplete character of 
the eruption in second attacks of scarlet fever, which, though uncommon, 
are met from time to time. Scarlet fever occurring a second time some- 
times presents all the features of the regular disease and pursues its nor- 
mal course, but it is much more apt to be incomplete and irregular than 



COMPLICATIONS. 161 

the first attack. It is more apt to be irregular if the interval between 
the two has been short than if several years have elapsed. 

Malignant Form. — This form of scarlet fever is in some epidemics 
common, while in others it is rare. It usually commences with severe 
symptoms, those pertaining to the nervous system predominating, such as 
intense cephalalgia, with delirium. Many pass rapidly intq coma and die 
within two or three days. They succumb to the virulence of the scarlati- 
nous poison, while the disease is still in its commencement. The rash in 
malignant scarlet fever is dusky. It disappears by pressure, and returns 
slowly when the pressure is removed. There is, therefore, extreme slug- 
gishness of the capillary circulation. In some there is great restlessness. 
If placed in one position on the bed they soon throw themselves, in a 
half-conscious or unconscious state, into anoth'er. They do not speak at 
all, or they mutter like those affected by the graver forms of typhus, call- 
ing the names of playmates, or talking about things which interested them 
when well. There is great elevation of temperature, the thermometer, 
placed in the axilla, rising above 103° to 104°, even to 107°, and the heat 
of surface is pungent, except when the case approaches a fatal termination. 
The pulse from the first is rapid, numbering from 130 to 160 per minute. 
Sometimes there is great heat of head and body, while the limbs are cool. 
This is an unfavorable sign. 

Severe and dangerous nervous symptoms, as convulsions and coma, 
occur chiefly within the first three or four days. After this period the 
danger is mainly from exhaustion. Those who survive the onset of the 
disease, often have, in the course of a few days, severe pharyngitis, with 
inflammation of the lymphatic glands, and connective tissue around the 
angle of the jaw, accompanied by external swelling. The pharyngitis is 
attended by more or less secretion of mucus or muco-pus, which, some- 
times collecting around the entrance of the larynx, causes noisy respira- 
tion, or even, if the system is greatly prostrated, embarrasses respiration 
by entering the larynx. The chief danger, however, from the pharyngitis, 
is due to the exhaustion which it causes. By rendering deglutition diffi- 
cult, it interferes seriously with nutrition. 

Complications. — Complications may occur in any form of scarlet fever, 
but they are most frequent in malignant or grave cases. The most com- 
mon and serious complication, as regards the nervous system, is clonic 
convulsions. These occasionally occur at the commencement of the dis- 
ease, before the appearance of the rash, and many then recover, but I 
have not seen, nor have I heard, in my intercourse with physicians, of 
any case which recovered when convulsions occurred after the complete 
development of the eruption. On the other hand, some of the physicians 
of this city, of largest experience, inform me that they consider convulsions 
during the eruptive stage an almost certain precursor of death. Convul- 
sive attacks in scarlatina are probably due, in part, to congestion of the 

11 



162 SCARLET FEVER. 

nervous centres, for we sometimes find, in young childreu, at the time of 
the seizure, and immediately before it, the anterior foutanelle prominent, 
and forcibly pulsatiug. The convulsions uniformly increase the conges- 
tion, but, as the latter antedates the former, its causative relation seems to 
be established. But the most important element in the causation of con- 
vulsions in scarlet fever is, probably, the presence in the blood of the 
scarlatinous virus. This, whatever its exact nature, may, in my opinion, 
cause convulsions, with or without the co-operating influence of congestion, 
as urea gives rise to them in cases of uraemia. Convulsions occurring at 
the commencement of scarlet fever are usually single. If repeated, they 
become more serious. Convulsions after the appearance of the eruption, 
either end at once in coma, or they return at short intervals, with gradu- 
ally increasing drowsiness, till coma supervenes. 

The anginose affection in scarlet fever may be so severe, or assume such 
features, as to constitute a complication. It may become more serious than 
the primary disease itself, so as to require the chief treatment. During the 
recent epidemics of diphtheria in this city many cases have been observed 
in which diphtheria and scarlet fever coexisted. As has been stated else- 
where, a pseudo-membranous formation upon the faucial surface, especially 
over the tonsils, is not uncommon in severe anginose scarlet fever, but is 
soft or pultaceous, in isolated points or patches, and easily detached. On 
the other hand, in the cases to which 1 have alluded, of diphtheritic com- 
plication, the pseudo-membrane is firm and thick, penetrating the mucous 
membrane so as to produce bleeding when forcibly detached, as in primary 
diphtheria. Besides affecting the fauces, the diphtheritic inflammation is 
very apt to attack the nostrils, causing swelling and exudation, so as often 
to embarrass respiration. This complication obviously greatly increases 
the severity of the case. It intensifies the febrile movement, and renders 
it more protracted. It produces or increases the adenitis and cellulitis 
around the angle of the jaw, causing within a few days, if unchecked, such 
tenderness and swelling of these parts as to render movements of the jaw 
and deglutition painful. 

An occasional result of severe pharyngitis in scarlet fever is suppuration, 
or gangrene occurring in the subcutaneous connective tissue of the neck. 
Whether suppuration occur, and an abscess form, or gangrene result, this 
complication is often serious. Suppuration or gangrene indicates an in- 
tense grade of inflammation or a low vitality ; but many with this com- 
plication recover thi'ough a protracted convalescence. 

If suppuration is extensive, it may so increase the debility that death 
occurs in consequence. Gangrene is a more serious complication ; unless 
slight, it renders a fatal termination highly jjrobable. The connective 
tissue, subcutaneous or intermuscular, is the part which primarily sloughs. 
The skin over the gangrene becomes brown or dark, and separates with the 
slough. In the majority of cases the slough is not large. Exceptionally 



COMPLICATIONS. 163 

it extends so deeply that, when it separates, the muscles and even vessels 
of the neck are laid bare, and the appearance is revolting. In a case of 
this sort, which I saw a few years *ince in the practice of another phy- 
sician, the cavity, after the slough had separated, was irregular, and 
sufficiently large to admit a hen's egg. It extended a considerable dis- 
tance out of sight under the skin, and finally opened a vessel from which 
fatal haemorrhage occurred. 

Gangrene of the mouth also occurs in rare instances, either as a com- 
plication or sequel. I have met it in two cases, one of which recovered. 
In the fatal case it began while the patient was still under treatment for 
the fever, and was first discovered by the loss of two incisors. The one 
that recovered also lost two incisors, and a pai't of the superior maxillary 
bone. The one that died was scrofulous, though its regimen was good; 
the other lived in a tenement-house, and was ill cared for. Rilliet and 
Barthez relate three cases of gangrene of the mouth, occurring, however, 
not as a complication, but sequel, of scarlet fever. One of these patients 
had, within eighteen days, varioloid, scarlet fever, and measles; these dis- 
eases ending in fatal gangrene of the pharynx and cheek. The second 
child was taken, on the seventeenth day after the commencement of scarlet 
fever, with gangrene of the pharynx, succeeded by that of the cheek, and 
died on the twenty-fourth day. In the third case the gangrene was pre- 
ceded by small-pox as well as scarlatina. Other observers have recorded 
similar cases. 

Another complication, to which allusion has already been made, is 
entero-colitis. This may antedate the scarlet fever. In other cases, 
entero-colitis commences either with the scarlet fever, or during its course. 
Diarrhoea often occurs in connection with the vomiting, in the first hours 
of the fever ; and it commonly ceases during the first or second day. Oc- 
casionally it continues with greater or less severity, when it constitutes a 
serious complication ; it is in these cases due to intestinal inflammation. 
Bronchitis and pneumonia, so common in measles, do not often complicate 
scarlet fever. 

A not infrequent complication is articular rheumatism, occurring when 
the fever begins to decline. Mild cases are more liable to it than those 
having a severe form. Attention is called to it by the complaint of the 
child of pain or tenderness in the affected joints ; or, if he is too young to 
speak, by evidences of pain when the joints are pressed or moved. There 
are usually but little swelling and redness, and there are fewer' joints 
affected than in most cases of acute primary rheumatism. In my practice, 
a common seat of scarlatinous rheumatism has been the areolar tissue of 
the wrist. The inflammation and infiltration are less than in primary acute 
rheumatism. This complication is not, ordinarily, serious ; nor does it, as a 
rule, materially retard convalescence. A physician of this city, however, 
informs me of two cases in which cardiac inflammation occurred in connec- 



164 SCARLET FEYER, 

tiou with the articular affection, as it so frequently does in idiopathic 
rheumatism. The urates are not so commonly present in the urine in 
scarlatinous as in ordinary acute rheuniatism. 

Serous inflammation, especially that affecting the peritoneum, pleura, or 
pericardium, is a common complication, independently of the rheumatic 
affection. It occurs during the desquamative period, and, continuing 
afterwards, becomes a sequel. Many such cases are fatal. Pericarditis 
may be with difficulty diagnosticated, if it is slight, and attended by only 
a moderate amount of effusion, and it is, doubtless, often the cause of death 
iu those who die suddenly and unexpectedly during or soon after an attack 
of scarlet fever. The pleuritis is often suppurative (empyema), usually 
requiring thoracentesis for its cure, but recovery by ulceration is possible. 
Thus in 1865 I attended a little girl in a mild attack of the fever, and 
when the case was about being discharged, severe pleurisy began on the 
right side. The pleural cavity was soon half filled with liquid, and after 
a sickness of two months, this liquid, mainly pus, communicated with a 
bronchial tube, and was expectorated. She immediately recovered. 

In the following case, the records of which are from my note-book, peri- 
cardial and peritoneal inflammation occurred as a complication of scarlet 
fever : 

Case. — April 7th, 1860, C , girl, five years and ten months old, had 

measles two years, and hooping-cough one year ago. With the exception 
of a slight cough, she has since remained well, till the present sickness. 
Scarlatina commenced April 4th, and on the 5th the eruption appeared. 
Symptoms severe, but regular; pulse 158, full ; surface hot, and covered 
with tiie eruption; delirium at night; stomach irritable; constipation. 
April 8th to 10th, symptoms about the same ; no delirium, however ; pulse 
varying from 124 to 153 per minute ; a deposit of urates in the urine. 

11th. To-day, for the first, has severe pain in the epigastrium, accom- 
panied by tenderness on pressure, and moderate distension at this point. 
The symptoms otherwise are favorable, though pretty severe ; pulse 140; 
respiration moderately accelerated, but the rhythm natural ; respiratory 
murmur distinctly heard in all parts of the chest, vesicular iu character, 
and without rales. Has taken till to-day mainly diaphoretic mixtures; 
to-day pulv. ipecac, comp., gr. iij, every three or four hours, is ordered ; a 
flaxseed poultice to be applied to the epigastrium ; diet nutritious, with 
moderate use of stimulants. 

12th. Epigastric pain still severe; great tenderness on pressure; con- 
siderable distension at this point, and percussion elicits a dull sound ; 
passed a restless night ; when asked where she feels pain, she points to the 
throat and epigastric region ; pulse 130 to 140 per minute; rash fading; 
surface warm ; bowels somewhat relaxed ; urine passed in usual quantity. 
The treatment by Dover's powder and poultices is continued, and a leech 
is to-day applied to the epigastrium. 

13th. Pain less severe, but considerable tenderness on pressure; pulse 
about the same as yesterday ; has had through her sickness a slight cough. 
She talks rationally, and sits much of the time in bed. 

14th. Continued in the same state as described in yesterday's records, 
till 3 P.M. yesterday, when she became suddenly worse ; her respiration 



SEQUELS. 165 

was short and gasping ; she spoke, with an effort, in a whisper, but con- 
tinued conscious ; and her pulse was strong. Death occurred at 5 p.m., 
apparently from obstructed respiration. In the last d.ays of her sickness 
there was but little pharyngitis, and little or no external swelling. 

Autopsy tiventy-four hours after death. — Body a little emaciated; heart 
large for a child of five years; about one ounce of turbid serum in the 
pericardium ; a soft deposit of lymph within the pericardial sac at the 
base of the heart arouud the origin of the great vessels, an evidence of recent 
circumscribed pericarditis ; from four to eight ounces of transparent serum 
in each pleural cavity ; no fibrin upon or opacity of the pleural surfaces ; 
mucous membrane of bronchial tubes injected in streaks, and muco-pus 
can be pressed from them ; both lungs can be readily inflated, with the 
exception of small portions of both the lower lobes, which are hepatized, 
and can be but partially inflated ; liver enlarged, presenting a congested 
appearance, and extending some four inches below the free border of the 
ribs ; upon its convex surface in the epigastrium, corresponding with the 
seat of the pain, is a white, rough patch of fibrin, about one and a half 
inches in diameter ; kidneys congested ; stomach and small intestines 
apparently healthy ; mesenteric glands moderately enlarged ; mucous mem- 
brane of transverse and descending colon somewhat injected and thickened, 
showing mild colitis ; no ulceration noticed ; brain not examined. 

Microscopic examination was made of the blood, hepatized portions of 
lung, etc., but nothing of special interest in this connection was observed. 

This case is instructive as showing the liability which exists in and after 
scarlet fever to serous inflammations, and the difficulty of diagnosticating 
them in certain cases on account of their circumscribed character. 

Sequels. — The complications described above may occur as sequelae, 
but there is another pathological state which may be a complication, and 
is a common and serious sequel. I refer to nephritis with albuminuria. 
This occasionally commences in scai'let fever, but usually not till the dis- 
appearance of the rash. There is sometimes, during the course of scarlet 
fever, and even subsequently, slight albuminuria due to simple congestion 
of the kidneys, but the albuminuria to which I allude, and which requires 
treatment, is more serious. Its anatomical character is as follows : Hy- 
persemia, and perceptible increase in volume of the kidneys; proliferation 
of the renal epithelial cells like that of the epidermis, and a granular 
deposit in them ; the escape of albumen from the engorged capillaries, 
and its appearance in the urine; the formation of fibrinous casts in the 
tubuli uriniferi, these casts often containing more or fewer epithelial cells; 
the escape of the easts from the kidneys with the urine ; diminution of 
amount of urea excreted, and, therefore, its accumulation in the blood; 
and, finally, rupture of the engorged capillaries of the kidneys, and min- 
gling of the elements of the blood with the urine. 

The presence, therefore, of this renal affection can be readily ascertained 
by examining the urine. The quantity of albumen which this liquid 
contains can be approximately ascertained by adding nitric acid or ap- 
plying heat. If the quantity is small, simple cloudiness is produced ; if 



166 SCARLET FEVER. 

large, the urine becomes thick and white, and in extreme cases almost 
semi-solid from coagulation of the albumen. The character of the urine 
can, however, be more accurately ascertained by the microscope than by 
the tests which have been mentioned, since by it we discover the fibrinous 
casts, altered epithelial cells, and blood-corpuscles. 

Nephritis, with the consequent uraemia, soon gives rise to evident symp- 
toms. Serous effusion takes place in consequence of the altered state of 
the blood, the most common form of which is anasarca, occurring upon the 
face and limbs, and sometimes in the connective tissue of the trunk. Often 
the effusion occurs only in the external connective tissue, and the result is 
then favorable ; but in other cases it occurs, and in the order mentioned 
as regards frequency, in the lungs (oedema pulmonum), serous cavities, 
and, lastly, in the submucous connective tissue of the larynx (oedema glot- 
tidis). The internal effusion should excite the gi-avest apprehensions, as 
it is often fatal. Fortunately, it is in most cases preceded, as well as 
accompanied, by anasarca, which is easily detected, so that there is suffi- 
cient forewarning. The fact of an occasional exception to this rule should 
be borne in mind. 

Scarlatinous nephritis, with consequent uraemia, is due to the direct 
effect of the scarlatinous poison on the kidneys. I have known it occur in 
the nurse who attended a child through the fever, but did not suffer from 
the fever herself It sometimes occurs quite abruptly, and often when the 
patient has been progressively convalescing, and, perhaps, has seemed out 
of danger. In most cases, however, there are well-marked premonitory 
symptoms, as fever, restlessness, loss of appetite. The anasarca is first 
observed in the face or about the ankles. Sometimes it remains inconsid- 
erable, but in other cases it increases day by day, more or less rapidly, 
till the appearance of the patient is much altered. In marked cases of 
anasarca the features are so bloated that their natural expression is lost. 
The volume of the trunk and legs is augmented, and more slowly, that of 
the arms. In the male child the penis and scrotum frequently attain 
three or four times their normal dimensions, in consequence of serous infil- 
tration. 

The duration of the anasarca or dropsy is very different in different 
cases. If the form be oedema pulmonum, oedema glottidis, or intracranial 
effusion, death is speedy. It may occur even within a day. Hydrothorax 
and hydropericardiura are also ordinarily fatal, though not so speedily ; 
while in ascites the prognosis is much more favorable. The duration of 
anasarca under the most favorable circumstances, unless it is very slight, 
is commonly not less than two or three weeks, and is often much longer. 
There is another and an important source of danger apart from the serous 
effusions, namely, the retention of urea in the blood. Convulsions, coma, 
and death may occur from uraemic poisoning, as in Bright's disease. In 
such cases there is great and continued scantiness of urine, in consequence 



SEQUELS. 167 

of obstruction in the tubuli uriuiferi from fibrinous casts and granular 
and swollen epithelial cells. 

The liability to this renal affection is greatly increased, and in some 
cases is mainly attributable to the close relationship, as regards their 
functions, which exists between the skin and kidneys. A common ex- 
citing cause is exposure to vicissitudes of temperature or currents of air, 
by which the surface is chilled, and cutaneous transpiration checked, at 
the time when the old epidermis is being detached. The increased burden 
thrown upon the kidneys results in the pathological state which has been 
described. This remark does not conflict with the statement already made, 
that the nephritis is due to the direct effect of the scarlatinous principle on 
the kidneys, the disturbance of the function of the skin merely increasing 
the functional activity of these organs and rendering them more susceptible 
to the disease. All who have seen much of scarlet fever can recall to mind 
cases in which the patients had nearly recovered, when from some needless 
exposure in the streets, or by chilling of the body in a cold room, or open 
window, this affection occurred, with perhaps a fatal result. Elsewhere I 
have alluded to a case in which scarlet fever was only detected by this 
sequel, which began when the child was daily exposed in the open air. 
But many children who have been attended with the utmost care, and 
who, through the whole desquamative period, are kept in a uniform tem- 
perature, nevertheless become affected with albuminuria and dropsy, so 
that there is sufficient cause of this sequel in the state of the child and the 
nature of the disease through which he has passed, apart from extraneous 
influences. It is an interesting fact that albuminuria is more apt to occur 
after mild than severe cases of scarlet fever, and observations show that 
this difference in liability to albuminuria is intrinsic ; in other words, that 
it does not depend, as some have supposed, on a difference in the hygienic 
management of mild and severe scarlatina. 

The symptoms in scarlatinous nephritis vary not only according to the 
degree of the inflammation, but also according to the amount and seat of 
the effusion. I have stated that it usually commences with languor and 
more or less fever. The pulse remains accelerated, the skin is hot and 
dry, and the appetite poor. This affection, if slight, may occur without 
appreciable effusion, either in the connective tissue or the cavities, but ordi- 
narily in these mild cases a little puffiness is observed around the eyes or 
upon the extremities. In the majority of cases more extensive anasarca 
results. The skin is then pallid, distended, and pitting on pressure. The 
anasarca does not, in most instances, give rise to any marked symptoms. 
If oedema glottidis or pulmonum occur, the respiration becomes rapidly 
more embarrassed, till soon the blood is no longer sufficiently oxygenated 
for the purposes of life. The chief symptom in hydrothorax is accelerated 
and difficult respiration ; in hydropericardium the symptoms are such as 
arise from embarrassed action of the heart ; in ascites there are either no 



168 SCARLET FEVER. 

marked symptoms, or, if the amount of liquid is large, there may be more 
or less embarrassment of respiration from compression of the lungs. 

OforrJuea. — Inflammation of the external ear, giving rise to otorrhoea, 
is a frequent sequel of scarlet fever. It sometimes commences as a com- 
plication in the last stages of the fever ; at other times it begins during 
convalescence. It often produces a degree of deafness, which, in most in- 
stances, soon passes off. A thin, purulent discharge from the ear may 
remain for months or even years, and hence the name which designates 
this affection. In exceptional cases, internal otitis occurs. This is a more 
serious sequel ; it may impair the hearing permanently. There are cases 
in which not only the drum of the ear is destroyed, but the ossicles are 
detached, and lost through the external ear. Complete deafness then 
results. I have met one case, in which both ears were so injured by scarlet 
fever in infancy, that the child grew up a mute. The result is sometimes 
still more serious. The inflammation may extend inwards, causing caries 
of the petrous portion of the temporal bone, till it reaches the lateral or 
petrosal sinuses. The inflammation then causes thickening and bulging 
of the walls of the sinuses, and, consequently, partial obstruction to the 
circulation, congestion in the veins and sinuses, the formation of thrombi, 
and finally coma and death. Fortunately, this melancholy termination 
of scarlatinous otitis is not frequent. 

A^TATOMICAL CHARACTERS. — There is some difficulty in determining 
what are the anatomical characters of scarlet fever, since so many who 
die of this disease have a complication, and the lesions of this are super- 
added to those of the fever. The following, however, are the facts which 
have been ascertained in reference to this point. In many the brain, its 
membranes, and the lungs are congested ; often, also, the Peyerian, soli- 
tary, and mesenteric glands are enlarged, and the spleen enlarged and 
softened. The liver and kidneys do not present any notable alteration, 
though the latter are so often affected during the period of convalescence. 
Dr. Samuel Fenwick (London Lancet, July 23d, 1864) has made post- 
mortem examinations in sixteen cases of scarlet fever, and concludes from 
them that there is inflammation of the mucous membrane of the stomach 
and intestines like that of the skin, and that there is desquamation of the 
epithelial cells from those portions of the digestive tube like that of the 
epidermis. I have had opportunity of examining the stomach and intes- 
tines in a few instances in those who died in the eruptive stage, in the 
Nursery and Child's Hospital, and did not find any unusual hyperemia 
of the gastro-intestiual surface, unless when gastro-intestinal inflammation 
had occurred as a complication. In malignant cases, in which the cardiac 
systole is feeble in the last hours of life, ante-mortem coagulation of fibrin 
frequently occurs in the cavities of the heart, obstructing the circulation, 
and being the immediate cause of death. These clots are large and 
whitish, or yellowish-white. 



NATURE. • 169 

Nature. — Scarlet fever presents in a marked degree the distinguishing 
features of the contagious affections. It is highly infectious ; it is also 
inoculable. Stoll, d'Amboise, and others successfully inoculated with the 
scarlatinous virus, using the blood, but without diminishing the intensity 
of the disease. Whether scarlatina ever originates spontaneously is un- 
certain ; but if it do, such cases are rare. It is disseminated by exposure 
to patients or fomites, though the distance to which it is contagious is 
short, probably not more than two or three yards. Some consider the 
distance to be even less than one yard. Knowledge of this fact is impor- 
tant, as by isolating in a family a child attacked by scarlet fever, and 
allowing no communication with the nurse, the other children often es- 
cape. A very common mode of communication is by clothing, so that a 
third person is the medium of transmission. I have noticed that when 
scarlet fever, as well as measles, is epidemic in this city, a large propor- 
tion of the cases, nearly all, indeed, of the first cases, can be traced to the 
public schools. Exposure occurs through those children who come from 
apartments where cases are under treatment. Physicians, and especially 
nurses, are sometimes the medium of communication, A medical friend 
of mine went directly from some children with scarlet fever, whom he was 
attending, to another family, where he took a little girl upon his knee. 
This gii'l in a few days became affected with scarlet fever and died. The 
two remaining children in the family were then attacked, and one died. 
Murchison alludes to similar cases (London Lancet, August 13th, 1864). 
In one instance in my practice scarlet fever was communicated to an 
infant by a washerwoman whose own child had the disease, and who, on 
reaching the house where she had been engaged to work, threw her shawl 
over the cradle where the infant was sleeping. Six days later the infant 
was attacked. Mason Good cites a case where a box of toys was the 
medium of communication ; and it is said that even a letter has been. 
The scarlatinous virus may remain for weeks and even months in apart- 
ments, clothing, or in or upon the person of one who has been affected, 
without any appreciable diminution in its effectiveness. A physician of 
this city, in whose family scarlet fever occurred, excluded a child from 
the room occupied by the patients, and from the patients themselves, for 
a month after the last case occurred, and yet, although precautious had 
been taken in reference to clothes and bedding, this child was taken with 
scarlet fever soon after it was allowed to mingle with the other children. 
The father believes that the exposure was through the otorrhoea of one of 
the children. Observations, indeed, appear fully to establish the fact that 
the discharge from the ear or nostrils, and the particles of epidermis 
which have exfoliated, may retain the virus and be the medium of com- 
municating the malady several weeks after the fever has terminated. In 
a case in my practice a little girl returned home six weeks after her 
brother had scarlet fever, and, within a few days, took the disease. A 



170 SCARLET FEVER. 

more strikiug example occurred in the practice of Dr. Kearney Rogers, 
formerly a prominent and much-esteemed surgeon of this city, and was re- 
lated to me by an intelligent friend of the family since the Doctor's death. 
Six children in a family had scarlet fever. Three and a half months sub- 
sequently another child, living at a distance, was allowed to visit them in 
the apartments where they had been sick. One week from that day this 
child also sickened with the same malady. Dr. Elliotson states that a patient 
with scarlet fever was admitted into one of the wards of St. Thomas's 
Hospital, and, for two years subsequently, young persons who were ad- 
mitted into this ward were apt to take the disease. Dr. Richardson re- 
lates the case of a family of four children, residing in the country. One 
died of malignant scarlet fever, and the rest, who had been removed, es- 
caped. Some weeks subsequently one of the children returned, but within 
twenty-four hours took scarlet fever and died. The cottage was now thor- 
oughly cleaned, whitewa.shed, and the clothing destroyed. Four months 
then elapsed, when the third child returned home, who also took scarlet 
fever in a malignant form and died. It was believed that the virus re- 
mained attached to the thatch, which extended close to the children's bed. 
Other similar examples might be mentioned, sufficient to e.stablish the 
fact of the great permanence of the scarlatinous virus. 

The period of incubation in scarlet fever varies. It is seen in the re- 
markable example of contagion, given above, that it was only twenty-four 
hours. Trousseau also relates an interesting example of short incubation. 
" An English gentleman with his daughter was returning from Pau to 
London, and was joined at Paris by another daughter, who came direct 
from London. Scarlet fever was prevalent in London, but there was not 
a case of it at Pau. The second daughter was seized with scarlet fever in 
crossing the Channel, and joined her relatives in Paris seven or eight hours 
later. She occupied the same room in the hotel as her sister, who was also 
attacked within twenty-four hours." The incubative period is, however, 
seldom so short. It is usually from three to eight days. I might cite 
several cases in which this was its duration. Some writers allude to cases 
in which two, three, or even four weeks elapsed from the time of exposure 
to the appearance of the disease. It is, however, a question whether in 
such cases there may not have been a second and more recent exposure. 
Rostan alludes to cases in which scarlet fever was communicated by inocu- 
lation, and in which the period of incubation was seven days. 

Scarlet fever occurs most frequently between the ages of three and ten 
years. It is infrequent under the age of one year, and infants under the 
age of three months may be considered safe from an attack of it, though 
fully exposed. Cases have been reported of scarlet fever occurring in the 
foetus, and manifesting itself by the usual signs at birth. But a clear 
diagnosis in such instances is necessarily difficult, on account of the char- 
acter of the scarlatinous eruption on the one hand, and the nature of the 



DIAGNOSIS. 171 

cutaneous circulation in the newly born on the other. It is probable that, 
in the cases alluded to, there was an error of diagnosis. Certainly in two 
instances I have known women immediately after their confinement (within 
a week) take scarlet fever, and although they communicated the disease to 
others, did not to their infants. Murchison states that twice he has known 
women with scarlet fever to be confined, and in both instances the infants 
were healthy. 

Most adults possess immunity from scarlet fever, although not protected 
by an attack of it in childhood. Parturient women, however, are liable to 
it, and there is considerable danger that the physicians who attend them, 
if at the same time visiting cases of scarlet fever, may communicate it to 
them. 

Scarlet fever is sometimes sporadic, but, as we meet it in this country, 
it occurs most frequently as an epidemic. The epidemics vary greatly in 
type. Some are mild, and attended by few complications, so that the re- 
sult of treatment is eminently satisfactory. In other epidemics the type is 
malignant, the complications frequent, and the percentage of deaths large, 
There is sometimes a succession of epidemics of one type, and then the 
character of the disease changes. This fact of a variable type is important 
as regards the value of statistics relating to treatment. Each epidemic has 
its prevailing character, but when the form is mild, there is now and then 
a case of severity, and when it is malignant, now and then one of unusual 
mildness. The epidemic influence is sometimes manifested in those ex- 
posed to scarlet fever by the occurrence of pharyngitis, and, as we have 
seen, nephritis. Professor George B. Wood, of Philadelphia, says (^Treatise 
on the Practice of Med.): "I seldom attend cases of scarlet fever without 
having sore throat." 

Scarlatina usually occurs but once in the same individual, but a second 
attack after the lapse of several years is not uncommon, and there are even 
cases on record of a third attack. But physicians sometimes mistake roseola 
or erythema for scarlet fever, and, though afterwards aware of their mistake, 
do not correct their diagnosis. Hence there is a belief in the community 
that second attacks of scarlet fever are more frequent than they really are. 

Diagnosis. — In the commencement of scarlet fever, prior to the erup- 
tion, there are no symptoms or appearances which will enable us to make 
a positive diagnosis. Positive statement in reference to the nature of the 
disea.se might better be deferred, for the credit of the physician. Still, if a 
child with regular bowels, and no appreciable local disease, a few days 
after exposure to scarlet fever, is suddenly seized with intense fever, the 
pulse rising to 110, 120, or more, and the temjierature to 102', 103°, or 
105°, there is little doubt that the disease is scarlet fever. The diagnosis 
is rendered more certain if there is vomiting, and especially if, as is often 
the case, there is, at this early period, a blush of redness upon the fauces. 

When the eruption has appeared, the nature of the malady is, in most 



172 SCARLET FEVER. 

cases, apparent. Still, roseola or erythema, due to intestinal derangement 
or other causes, has often, as already stated, been mistaken for scarlet 
fever. A day or two suffices to show the error. In scarlet fever there is 
more inflammation of the faucial and buccal surface, more continuous and 
persistent redness of the skin, and greater intensity and persistence of 
symptoms, than in those diseases. Scarlet fever is also further distin- 
guished from them by the jsapular elevations upon the tongue, and the 
minute papulse upon the skin. Besides, in scarlet fever, except in the 
mildest cases, there is from the first the aspect of serious sickness, which 
roseola and erythema do not present. 

Scarlet fever and measles were long considered identical by the profes- 
sion, and, though the ordinary forms of the two diseases can be readily dis- 
tinguished from each other, there are instances in which the differential 
diagnosis is attended by some difficulty. Measles occurring in a robust 
child, with an active cutaneous circulation, sometimes presents a continuous 
eruption over a considerable part of the surface, like the eruj)tion of scar- 
let fever. But the longer period of invasion, the coryza and bronchitis, 
and the absence or slight degree of pharyngitis, in connection with other 
symptoms, enable us to distinguish these cases from scarlatina. Moreover, 
in those cases of measles in which there is continuous redness of surface 
where the circulation is most active, as upon the face, the characteristic 
rubeolous eruption is present in other parts, so that, with care in examina- 
tion, error of diagnosis may be avoided. Scarlet fever and measles may 
indeed occur together, but such a complication is rare. 

The greatest difficulty of diagnosis occurs in abnormal scarlatina, espe- 
cially when the rash is partial and indistinct. There is apt to be, in this 
form of the disease, an inflammatory complication, which causes with- 
drawal of blood from the surface, and it is sometimes very puzzling to de- 
cide whether this is a complication, or the sole disease. The points in- 
volved in diagnosis are numerous, but they are sometimes not sufficient to 
show the character of the affection. Generally, however, by observing the 
clinical history from day to day, the diagnosis is established. In cases of 
doubt it is safest to adopt such hygienic management as is appropriate to 
scarlet fever. 

Prognosis. — The prognosis depends on the form of the disease, whether 
mild or severe, the presence or absence of complications, and the strength 
of the patient. The mortality varies greatly in different epidemics. In 
epidemics of a mild type, the mortality is sometimes not more than one in 
twelve, and the ratio may be less ; whereas, if a severe form is prevailing, 
not more than one recovers in every two, three, or four. The mortality is 
greater in the city than country, in hospital than in private practice. 
Rilliet and Barthez, in hospital practice, lost forty-six out of eighty-seven. 
Scarlatina is, of itself, less fatal than statistics would lead us to suppose, 



TREATMENT. 173 

since a large proportion of those who die in consequence of it die from com- 
plications or from sequelae, rather than from the primary disease. 

The symptoms, in the first days of scarlet fever, which indicate an un- 
favorable termination, are convulsions, except at the very commencement, 
great drowsiness, with jactitation, great elevation of temperature, a rapid 
pulse, duskiness of the eruption, and feeble capillary circulation. At a 
later period, particularly in the second week, other unfavorable symptoms 
may occur in malignant and fatal cases. Violent pharyngeal inflamma- 
tion, with great external swelling from the adenitis and cellulitis, is apt to 
be present at this stage of the disease. Severe inflammation of this char- 
acter, as indicated by the tumefaction, greatly increases the danger. 

As there are several complications and sequelse of a dangerous charac- 
ter, and as these are apt to occur suddenly, and often without appreciable 
existing cause, in mild as well as severe cases, it is unwise ever to make an 
unconditional favorable prognosis. The patient is not to be considered 
entirely safe till two or three weeks have elapsed after the eruption. 

Some patients who have passed through scarlet fever, die of asthenia, in 
consequence of the ansemic state which the fever has produced. They 
have not sufficient vigor of system to recover, although no serious compli- 
cation or sequel has occurred. In other cases the pharyngitis and cellu- 
litis, attended with tumefaction, rendering deglutition painful, and keep- 
ing up the febrile movement after the primary disease has run its course, 
have much to do in producing a state of exhaustion and death. But the 
mortality in the desquamative stage, and subsequently, is more frequently 
due to the renal affection, which is so common, than to any other cause. 
This affection gives rise to dropsies, wdiich are fatal, or to ursemic convul- 
sions, and coma. Sudden and unexpected deaths are not uncommon in 
scarlet fever, and it is probable that, in many of these cases, the immedi- 
ate cause is ursemia, which, not having produced any conspicuous symp- 
toms till near the close of life, is not discovered. 

Treatment. — Scarlet fever, when mild, and without complication, re- 
quires little treatment. A gentle cathartic should be given from time to 
time, if there is a tendency to constipation, and a simple diaphoretic as 
spiritus Mindereri, or the following mixture, is all that the case requires: 

R. Spts. ffithcr., nitr., 
Syr. ipecac, fu'i ^ij. 
Syr. simplic, 5 j. Misce. 
Dt)se, one toaspoonful every three hours to u child of three to five years. 

If there is restlessness, an occasional dose of bromide of potassium with 
a warm mustard foot-bath will give relief; and if there is considerable 
fever, as indicated by flushed face, heat of head, cephalalgia, or other 
nervous symptoms, cool applications should be made to the head, and the 
face and forehead occasionally bathed with cool water, bay rum, or other 



174 SCARLET FEVER. 

cooling lotion. The mildest cases indeed commonly do well without treat- 
ment, except hygienic, though it may be necessary, in consequence of the 
impatience of the family, to prescribe a placebo. When the fever has 
begun to abate, in such cases, if the appetite returns, and there is no com- 
plication, and no symptom of feebleness, there is little for the physician to 
do. But if, as is sometimes the case, even when the disease has been mild, 
the appetite remains poor, and the aspect is anaemic, tonics are required, 
especially chalybeates. 

The majority of cases, however, demand more decided measures than 
those described above. We pass to the consideration of cases of moderate 
severity, and those of a grave character. Trousseau recommends cold 
affusions as an important part of the treatment. They should be employed 
in the first stage of sthenic cases. They are especially beneficial, it is 
stated, in those cases in which nervous symptoms predominate. The 
patient is placed naked in a bathing-tub, and three or four pails of water 
are thrown over him, in a space of time varying from a quarter of a 
minute to one minute, after which he is covered with bedclothes, without 
being wiped. Reaction immediately occurs, often with more or less per- 
spiration. This treatment is repeated once or twice, daily, according to 
the gravity of the symptoms. 

" Dr. Currie," says Trousseau, " was the first who made use of this 
treatment, and he established its applicability, as a general rule, in scarla- 
tina accompanied by grave nervous accidents, such as delirium, convul- 
sions, diarrhoea, excessive vomiting, considerable exaltation of the heat of 
surface." Trousseau believes that cold affusions diminish the febrile move- 
ment, and calm the nervous excitement, and he further adds: ... "I 
have never administered it without deriving some benefit." Public opinion 
is, however, so averse to such treatment of the eruptive fevers, that one of 
less authority than Trousseau would scarcely be able to employ it. The 
shock of such treatment to a child not sufficiently old to be reasoned with 
must be considerable, and it would seem questionable whether the excite- 
ment from such a measure may not increase the liability to clonic convul- 
sions. 

In the cases alluded to by Trousseau, in which there is great heat of 
surface, and nervous symptoms predominate, though cold affusions are not 
used, there is no doubt of the beneficial effect of cold applications to the 
head, and sponging the face and arms. This may be frequently repeated 
if there is great elevation of temperature. 

The medicinal treatment of scarlet fever has varied greatly at different 
periods, according to the theory which happened to prevail, and it is even 
now far from uniform. 

Depletion is rarely required in scarlet fever ; on the other hand, sus- 
taining measures are indicated from the first. Bloodletting, formerly 
more or less prescribed in the treatment of this disease, is now almost ob- 



TREATMENT. 175 

solete. In no instance is venesection required. Rarely in robust children, 
having an active circulation and a decidedly sthenic form of the disease, 
there might be a condition in which one or two leeches would be service- 
able ; as, for example, leeches applied to the temple, if there is evidence 
of dangerous cerebral congestion. But in these cases a sufficiently sedative 
or tranquillizing effect can, ordinarily, be produced by one or two large 
doses of bromide of potassium, the application of cold to the head, cold 
ablutions to the face and hands, and by an occasional warm general or 
foot-bath. In all malignant cases, measures which reduce the vital powers 
cannot fail to be injurious. In those cases which are properly designated 
by that name, there are often evidences of prostration from the first, as 
drowsiness, jactitation, delirium, languid circulation, evinced by the dusky 
hue of the surface. These symptoms indicate the need of stimulants. 

In the ordinary as well as severe forms of scarlet fever, carbonate of am- 
monia, administered with a tonic, is one of the best remedies. It is, more- 
over, recommended by the best authorities. It may be prescribed at the 
first visit of the physician, and continued at regular intervals. It is used 
as a main remedy by many judicious and skilful practitioners. I ordina- 
rily prescribe it in combination with citrate of iron and ammonia. 

R. Amnion, carbonat., 

Ferri et amnion, citrat., aa ^ss. _ 
SjT. simplic, 3iv. Misce. 
Dose, one teaspoonful every three hours, to a child of two or three years. 

An unpleasant symptom in most cases, and one which increases greatly 
the restlessness of the patient, is itching of the skin. The safest and best 
remedy for this is inunction. Fresh lard has sometimes been employed 
for this purpose. It relieves the dryness, and in a measure the heat of 
surface, and at the same time diminishes the itching. The odor from the 
lard is, however, offensive after it has been used for a day or two. An 
equally efficacious, more agreeable, but more costly substance for the in- 
unction is glycerin, which may be applied pure, or scented with one of 
the essential oils. Dr. J. F. Meigs recommends the following : 



R. GlyceriniK, 3J ; 

Ung. aq. rosre, 3J. Misce. 

I prefer to either of these applications the employment of sweet oil or 
glycerin, to each ounce of which about six or eight drops of carbolic acid 
are added. 

The inunction should be made with muslin or linen. Those parts of the 
surface which are the seat of itching should be frequently treated in this 
way, and occasionally the application may be made over the entire surface. 
Not only does inunction liave the local effect which has been described, but 



176 SCARLET FEVER. 

it is stated to diminish sensibly the rapidity of the pulse and the general 
temperature of the body. 

In malignant forms of scarlet fever, which are indicated by quick and 
weak pulse, a temperature rising to 105°, or higher, drowsiness, delirium, 
great restlessness, duskiness of the skin, and a languid circulation, the 
condition is one of great peril ; and the sulphate of quinine, in large doses, 
is, in my opinion, more useful than any other remedy. While it gives 
more strength to the action of the heart, it diminishes the frequency of the 
pulsations and reduces the temperature. Three to five grains may be given 
three times daily to a child of five years. Sometimes in these cases the 
stomach is very irritable, so that the quinine is vomited at once. Ten or 
twelve grains may then be given in a clyster, and if the excessive tempera- 
ture continue, it should be repeated after twelve hours. A hot mustard 
foot-bath, or general warm baths containing mustard, the free use of wine 
whey or milk punch, and, if great restlessness, the bromide of potassium, 
are also indicated. The mustard bath not only quickens the capillary 
circulation, producing a better color of the rash, or causing it to appear, 
if its development is retarded, but it calms the nervous excitement, and is 
often instrumental in preventing convulsions. If convulsions occur, which 
are attended by disappearance of the eruption, the bath should be em- 
ployed at once. In grave cases, in which the rash is indistinct, some 
physicians, whose opinions are entitled to consideration, employ belladonna 
in sufficient dose to cause an eruption. I am not aware, however, that 
the severity of scarlet fever is diminished by this agent, as thus employed, 
although the disease is apparently rendered more normal by its use, so far 
as the rash is concerned. 

The pharyngitis demands attention in most patients. Various modes of 
treating this have been recommended. The application to the throat of a 
cloth wrung out of cold water, or containing pounded ice, has been recom- 
mended ; but the continued wetting of the patient which such treatment 
necessitates, and the danger from constant cold applications of chilling the 
body and causing retrocession of the eruption, would deter the prudent 
practitioner from employing such measures. The preferable way to apply 
cold is by a small bladder, or segment of a bladder, containing pieces of 
ice, but with a thin slice of pork, or double thickness of flannel between 
it and the neck. 

As regards external treatment, I have been led to regard with most favor 
the use of a slice of salt pork, cut as thin as possible, and stitched to a sin- 
gle thickness of muslin or linen. The pork should pass from ear to ear, 
the cloth being tied or pinned over the vertex. If the pork is unpleasant 
to the child, or the skin easily irritated, camphorated oil ajiplied upon 
muslin suffices. If the pork is properly applied, the surface usually 
begins to be reddened in twenty-four hours, and, by the second day, an 
impetiginous eruption appears upon the part covered by the pork. Coun- 



TREATMENT. 177 

ter-irritation gradually produced in this manuer causes little sufferiug. 
Patients, ordinarily, do not complain of it at all. This application should 
be continued through the fever, being occasionally left off for a day or 
two, as too much soreness is produced, and linen soaked with sweet oil, or 
covered with a simple ointment, be applied in its place. 

But the employment of remedies, directly applied to the faucial surface, 
is much more eifectual in reducing the pharyngeal inflammation, and pre- 
venting inflammation of the cervical glands and connective tissue, which 
is so apt to supervene upon and complicate the faucial inflammation, and 
produce tumefaction along the sides of the neck. For the adenitis and 
cellulitis indicate a dangerous form of pharyngitis, and are, I believe, in 
many instances produced or intensified by absorption of the decomposing 
secretions, which are lodged in the depressions upon the faucial surface. 
Now gargles or washes, properly employed, not only diminish this inflam- 
mation, but prevent the septic poisoning. 

In New York City, where diphtheria may be said to be endemic, and 
where it complicates many cases of scarlet fever, producing dangerous 
pseudo-membranous inflammation of the fauces, daily inspection of the 
throat and early treatment of it are more urgently required than iu 
localities where diphtheria is still unknown or infrequent. Still, in any 
locality or case, intense pharyngitis, since it reacts on the system, inten- 
sifies the general symptoms, prevents the proper administration of nutri- 
ment, and is often the chief source of danger, should always receive special 
attention on the part of the practitioner. 

Gargles of a saturated solution of chlorate of potash, to which one of 
the astringent preparations of iron is added, or better, carbolic acid, in the 
proportion of three or four drops to the ounce, should be employed by 
those old enough to use them in cases of moderate or severe pharyngitis. 
In younger children, and in all cases in which the pharyngeal symptoms 
are urgent, we cannot rely on gargles, but must make direct applications 
to the throat by a large camel's-hair pencil every three or four hours, or a 
small quantity of the chlorate of potash may be swallowed every second 

hour. 

R. Acid, carbolic, gtt. xv-xxx. 
Potass, chlorate, ^iij. 
Glycerinse, 

Aquae, aa ^iij. Misce. 
For a gargle. 

The effect of carbolic acid in checking the muco-purulent discharge and 
relieving the inflammation is often very decided. 

R. Acid, carbolic, gtt. v. 

Liq. ferri-subsulpbato, ^ij. 
Glycerins?, ^j. Miscc. 
To be applied with a camel-hair pencil three or four times daily. 
12 



178 SCARLET FEVER. 

There is no application more effectual than this last in removing any 
exudation or viscid secretion, and by its powerful astringent effect dimin- 
ishing the turgescence of the inflamed surface. Yeast is also useful in 
many of these cases, given in the quantity of half a teaspoonful to a tea- 
spoonful several times daily. As it is swallowed it touches each part of 
the throat, and, if no drink is allowed, for a few minutes afterwards, it 
produces a healthy, stimulating effect on the diseased surface. The reader 
is referred to our remarks relating to the local treatment of diphtheria, 
much of which is also applicable to scarlet fever. 

Sometimes, in feeble children, viscid mucus collects in the pharynx and 
around the aperture of the glottis, so as to interfere with inspiration. In 
these cases there is danger of death from apnoea. Prompt interference is 
required. Swabbing the throat removes the mucus, which is attached to 
the swab, or is expectorated by the forced cough which the oj)eration 
causes. The swabbing may be performed by a piece of whalebone, bent 
at the end, and wound with linen or soft muslin. I usually employ it 
dipped in the solution of carbolic acid and chlorate of potash. I have 
sometimes relieved the most urgent dyspnoea by this means. An accumu- 
lation of mucus in the pharynx or larynx, so as to require mechanical 
interference, is most frequent in infants. 

The diet in scarlatina should be nutritious, consisting of animal broths, 
milk porridge, and the like. The patient will rarely take solid food, except 
in the mildest cases. Those affected with grave forms of the disease re- 
quire nutriment as regularly, night and day, as in typhus and typhoid 
fevers. 

In mild cases, alcoholic stimulants are not required, unless in moderate 
quantity towards the close of the disease. In severe cases, attended from 
the first with great prostration, they are needed throughout the entire 
course of the fever. Wine-whey or milk-punch should be regularly ad- 
ministered, in quantity according to the age of the child. The presence of 
severe nervous symptoms, as jactitation or delirium, in these asthenic cases, 
should not deter from its employment. Convulsions and coma are, in- 
deed, less likely to occur if stimulants are used, since the scarlatinous 
virus is, in a measure, counteracted by such agents. The apartment in 
which the patient is treated should be airy, and ventilated without ex- 
posure to currents of air. The temperature of the room should be uni- 
form, about 68° for robust children with high fever, about 70° for feeble 
children. It should be a little more elevated after the fever has abated, 
and the desquamative period commenced, than during the fever. The 
patient is, indeed, especially liable to be affected by changes of tempera- 
ture and currents of air in the two or three weeks succeeding scarlet fever, 
and this exposure is very apt to result in inflammations, such as have been 
described; therefore great care should be exercised in refej-ence to the 



TREATMENT. 179 

hygienic management of the patient during convalescence. In stormy 
weather he should be kept indoors for a month or six weeks. 

The nephritic affection, which is so common a sequel of scarlet fever, is 
often more dangerous than the primary disease itself A clear apprecia- 
tion of its therapeutic indications is important, since by judicious treat- 
ment many recover whose lives would inevitably be sacrificed by improper 
measures. As there is in these cases active hypersemia of the kidneys, 
having in most cases ad inflammatory character, diuretics which stimulate 
these organs should not ordinarily be given, at least till this pathological 
state has, in a measure, abated. As the eliminative functions of the skin 
and of the intestinal mucous surface are to a considerable extent vicarious 
with that of the kidneys, diaphoretic and purgative remedies are required. 
By free diaphoresis the ill effect of arrested or diminished renal secretion 
is, for a time, averted. Treatment to produce diaphoresis should vary 
somewhat in different cases. It should in most patients be commenced by 
the use of a warm general or foot bath, and the patient then be covered 
in bed. If free perspiration is not produced, it may be promoted by 
placing against the patient one or more bottles of hot water, surrounded 
by a wet cloth. The steam arising from this, and enveloping the body 
and limbs, produces a prompt sudorific effect. There is in use in this city, 
in the treatment of these and similar cases requiring diaphoresis, a con- 
venient apparatus for generating steam. It consists of a cylinder pierced 
with holes for the admission of air, and containing a spirit-lamp over 
which is a pan or pail holding a little water. The patient, nearly de- 
nuded, is placed in a chair, with the apparatus by his side, and is covered 
with a blanket so that the steam surrounds the body. This gives rise to 
free perspiration, which continues after the patient is placed in bed. This 
treatment may be repeated each day, if the patient require it, while di- 
aphoretics or cathartics are given. 

The diaphoretics which are most serviceable in this affection are the 
acetates of ammonia and potassa, the bitartrate and citrate of potassa. 
Spiritus fetheris nitrici, combined with either of these, increases the effect, 
if the surface is warm, especially if there is already diaphoresis from the 
bath or steam. Spiritus Mindereri may be given to a child of five years, 
in doses of two teaspoonfuls every two or three hours, either alone or in 
combination with sweet spirits of nitre, as in the following formula : 

R. Spts. ajther. nitrici, 3SS. 

Liq. ammon. acetat., ^iv. Misce. 

The acetate of potash is a more agreeable medicine, and it is generally 
quite as effectual. It should be given, dissolved in water or syrup, in 
doses of about one grain for each year of the child's age. Whatever 
diaphoretic is used has more effect, as has already been stated, if given in 
connection with the external measures designed to produce diaphoresis, 



180 SCARLET FEVEE. 

which have been described above. If perspiration is not produced, the 
action of the medicine is probably on the kidneys ; and if diuresis do not 
result, there is danger that the hypersemia of the kidneys will be increased. 
In such cases diaphoretics should be omitted and cathartic medicines 
given in place ; or, if there is much exhaustion, it is sometimes better to 
give no eliminative medicine, and to treat the renal affection mainly by 
local and external measures. 

In robust children suffering from scarlatinous urseraia and serous effu- 
sions no medicines afford so much relief in the commencement as cathar- 
tics of a hydragogue nature. A mixture of jalap and cream of tartar, 
pulvis jalapce compositus of the Pharmacopoeia, meets the indication. 
Even in children somewhat reduced medicines of this nature are often 
required. Cathartics are more certain in their effects than either diapho- 
retics or diuretics, and therefore they should be given in urgent cases in 
which it is necessary to remove the urea or serum as speedily as possible. 
An excellent prescription in many of these cases, and one from which I 
have obtained a good result, is the following : 

R. Podophyllin, gv. j. 

Sacch. alb., 9j. Misce. 
Divid. in chart. No. viii-xii. 
Doso, one powder, according to circumstances. 

When cathartic or laxative agents have been used two or three days, 
the kidneys, being less congested in consequence of the diversion that has 
occurred, often begin to excrete more freely. Subsequently to the employ- 
ment of medicines of this kind, or in connection with them, diaphoretics 
are in most cases required. The physician's experience, and his discrimi- 
nation in reference to the condition of the patient, will guide him in the 
selection of proper remedies to meet the indications. 

In a large proportion of cases, when this renal affection has continued 
one, two, or three weeks, the treatment which has been recommended 
above is no longer appropriate. There may be more or less anasarca and 
albuminuria, but the patient is anseniic, and evidently in need of sustain- 
ing measures, while there are no symptoms which indicate immediate 
danger from retention of urea or the excess of liquid in the system. In 
these cases the tincture of the chloride of iron is a most useful medicine. 
While it serves as a tonic, it seems also to have a diuretic effect. To a 
child of five years it should be given in doses of five drops, every three or 
four hours. 

If the patient is decidedly anaemic and feeble when the renal affection 
commences, and the symptoms are not urgent, it is best not to administer 
diaphoretics and cathartics, or to administer them sparingly, and to com- 
mence early with sustaining remedies. Cases like the following from my 
note-book are not infrequent. A little boy, pale and scrofulous, began to 



TREATMENT. 181 

have anasarca, after scarlet fever, chiefly of the scrotum, and accompanied 
by a moderate degree of ascites. The urine, which was passed in nearly 
the normal quantity, contained albumen. This patient gradually and 
fully recovered, with no treatment except the use of an oil-silk jacket 
over the kidneys and abdomen, to promote diaphoresis, and the use of 
iron. Such a case actively treated by eliminatives would, probably, have 
proved fatal. Uniform treatment for scarlatinous nephritis is therefore 
injudicious ; considerable variation in measures is demanded, according 
to the state of the patients. 

The otorrhoea of scarlet fever should not be neglected. It is apt to 
continue for months unless treated, and the hearing may become perma- 
nently impaired. There is danger, indeed, that the inflammation may 
extend inwards, with a most disastrous result. For this ailment there is, 
in my opinion, no remedy so useful as the following, which should be either 
dropped or syringed into the ear three times daily : 

R. Acid, carbolic, gss. 
Glycerin 88, ^ij. 
Aqua3, §iv. Misce. 

It is also very beneficial when the otorrhoea occurs from scrofula or 
other cause. When the remedial agents required for the fever are dis- 
continued, and the otorrhoea persists, cod-liver oil and the syrup of the 
iodide of iron, given in appropriate doses, will often be found useful, not 
only for the general health, but the otorrhoea. (See London Lancet, Dec. 
3d, 1870.) 

It is evident, from what has been said, that every possible precaution 
should be taken to prevent the patient's catching cold during the period 
of convalescence. He should not be allowed to go in the open air in 
uupropitious weather till a month after the fever. An oil-silk protection 
of the body, worn from the time that the febrile symptoms begin to decline, 
and covering the lumbar region, diminishes the liability to nephritis and 
uraemia. 

Prophylaxis. — Since the period of Jenner's discovery of the prophy- 
lactic power of vaccination, as regards small-pox, the attention of the 
profession has been frequently directed to the prevention of scarlet fever. 
A medicine has been sought which would antagonize and mollify, if not 
entirely prevent, the disease. Of late years it has been claimed that bel- 
ladonna, given during the period of exposure, and subsequently, is a pre- 
ventive. The first employment of this agent for such a purpose was based 
entirely on theoretical grounds, it being presumed that, as it produces an 
eruption of the skin and dryness of the throat, like those of scarlet fever, 
it is therefore antidotal. Whether or not belladonna does have such an 
effect can only be determined by experience, and latterly, as observations 
accumulate, the number does not seem to increase of those who believe in 



182 SCARLET FEVER.. 

its prophylactic power. Still, there is difference of opinion among good 
observei-s. The difficulty of determining jiositively the matter of prophy- 
laxis is apparent when we consider that many children who are exposed 
to scarlet fever do not take it, although nothing is done for the purpose 
of prevention. Burnett made use of the following prescription as a pre- 
ventive : 

R. Ext. bellad., gr. j. 

Aq. canelliB, ^ij. Misce. 

Two or three drops were given morning and evening to a child of one 
year, and one drop more for every year for children of a more advanced 
age. He administerd it to 120 infants, of whom only five contracted the 
disease. Schenck, half a century since, stated that, in the course of an 
epidemic, out of 525 persons who took belladonna only three contracted 
the disease. M. Biett, whose observations were made during the epidemic 
prevalence of scarlet fever in Switzerland, states that those to whom 
belladonna was given usually eScaped. On the other hand, Lehmann and 
Wagner may be mentioned among others on the continent, who believe 
that they have derived no benefit from the use of this medicine. These 
physicians have seen one-fourth to one-third of those to whom belladonna 
had been given take scarlet fever. In this country, observers differ in 
their estimate of the preventive effect of belladonna. Dr. Irwin, of South 
Carolina, as quoted by Dr. Condie, gave it to 250 children, and less than 
half a dozen took the affection. He employed a solution of three grains 
of the extract in an ounce of cinnamon-water, giving two or three drops 
to a child under the age of one year, and one additional drop for each 
year. Dr. Condie himself, however, has had a different experience. He 
has prescribed belladonna, "but, although redness and dryness of the 
throat, and a diffuse scarlet efflorescence, were produced in the majority 
of cases, we never," says he, " found it in any to exert the slightest influ- 
ence in mitigating the character or preventing the occurrence of scarlatina. 
The experiments were made during the prevalence of the disease, and in 
numerous instance the subjects of them were attacked. In one case the 
efflorescence was kept up by the use of belladonna forty-eight hours. In 
a week afterwards this individual took the disease in its most violent form, 
and died on the fourth day." My observations in reference to this use of 
belladonna are few, and they are not at all favorable to its employment. 
I have known scarlet fever occur, without apparently any modification, 
though belladonna was. administered daily. Those who have made trial 
of this medicine have administered it in very different doses. Hahnemann 
employed it in so small a dose, that it would seem, a priori, that it could 
have had no effect. Hufeland employed the following formula : 

R. Ext. bellad., gr. iij. 
Alcohol, 3J. 

Aq. destillat.. ^ss. Misce. 
Dose, one drop morning and evening for each year of the child's age. 



TEEATMENT. 183 

So small a dose would certainly do no harm, so that the medicine might 
be safely tried. Nevertheless, it is my opinion from the weight of evi- 
dence that this agent is entirely inert for this purpose. 

The great importance of the prophylaxis of scarlet fever has induced me 
to state what is known of the effects of belladonna employed for this pur- 
pose. I am, however, strongly of opinion that the most reliable prophylaxis 
is isolation, and the proper employment of disinfection in the sick-room 
and upon the patient. There can be no doubt that most of the excretions 
of a child sick with this malady contain the scarlatinous virus, as do also 
the cells of the epidermis, which are thrown off during convalescence, and 
minute particles of which are wafted aw^ay as motes in the air. By the 
proper application of washes, which contain carbolic acid, to the fauces 
and nostrils, the secretions from these surfaces are to a great extent dis- 
infected. If otorrhoea occur, the ear should be syringed with warm water 
containing carbolic acid in the proportion of one drachm to the pint, and 
this should be continued after convalescence, for cases occur which show 
that the discharge from the ear has probably been the medium by which 
the virus was communicated, even as late as the fourth week after the disap- 
pearance of the rash. Children in the midst of the fever usually experience 
a degree of relief from inunction of the surfaces, and if carbolic acid be 
added to the substance, which is employed for this purpose, and the inunc- 
tion be made twice daily over the entire surface, contamination of the air 
through the exhalations and exfoliations from the skin is in great part pre- 
vented. A convalescent child should not be allowed to mingle with other 
children till three or four weeks have elapsed, and all who are liable to take 
the malady should be excluded from the room in which a case has occurred 
for a longer period. 

The New York Health Board enforce the following excellent regulations 
against scarlet fever as well as measles : 

" Care of Patients. — The patient should be placed in a separate room, and 
no person except the physician, nurse, or mother, allowed to enter the room, 
or to touch the bedding or clothing used in the sick-room, until they have 
been thoroughly disinfected. 

"Infected Articles. — All clothing, bedding, or other articles not absolutely 
necessary for the use of the patient, should be removed from the sick-room. 
Articles used about the patient, such as sheets, pillow-cases, blankets, or 
clothes, must not be removed from the sick-room until they have been dis- 
infecte{|, by placing them in a tub with the following disinfecting fluid : 
eight ounces of sulphate of zinc, one ounce of carbolic acid, three gallons 
of water. 

" They should be soaked in this fluid for at least one hour, and then placed 
in boiling water for washing. 

" A piece of muslin, one foot square, should be dipped in the same solu- 



184 ROTHELN. 

tion aud suspended in the sick-room constantly, and the same should be 
done in the hallway adjoining the sick-room. . . . 

"All vessels used for receiving the discharges of patients should have some 
of the same disinfecting fluid constantly therein, and immediately after use 
by the patient be emptied aud cleansed with boiling w'ater. Water closets 
and privies should also be disinfected daily with the same fluid, or a solu- 
tion of chloride of iron, one pound to a gallon of water, adding one or two 
ounces of carbolic acid. 

"All straw beds should be burned. . . . 

"It is advised not to use handkerchiefs about the patient, but rather soft 
rags for cleansing the nostrils and mouth, which should be immediately 
thereafter burned. 

" The ceilings and side walls of the sick-room after removal of the patient 
should be thoroughly cleaned and lime washed, aud the woodwork and 
floor thoroughly scrubbed with soap and water." 

By such measures of prevention there can be no doubt that the number 
of cases of scarlet fever would be greatly reduced. Dr. William Budd, of 
Bristol, England, has for years recommended similar precautions in the 
families, which he attends, and the following is his testimony in regard to 
the result : " The success of this method, in my own hands, has been very 
remarkable. For a period of nearly twenty years, during which I have 
employed it in a very wide field, I have never known the disease to spread 
in a single instance beyond the sick-room, and in very few instances within 
it. Time after time I have treated this fever in houses crowded from attic 
to basement, with children and others, who have nevertheless escaped 
infection. The two elements in the method are, separation on the one 
hand, and disinfection on the other." {British Medical Journal, January 
9th, 1869.) 



CHAPTER III. 

KOTHELN. 

The disease known as rotheln is rare in this country. On the Conti- 
nent, especially in Germany, on the other hand, it has been known many 
years, and German writers describe it under the term rubeola, which we 
apply to ordinary measles. This nomenclature produces confusion in 
terms, aud hence rotheln is sometimes designated German measles. Meagre 
and imperfect descriptions of this malady have appeared in some of the 



ROTHELN. 185 

British journals, and cases quite full)^ detailed have also been published 
by British physicians. 

In this country rotheln is not entirely new, though most physicians have 
never seen a case of it. Cases occurring in or about Boston were described 
by Dr. Homans, Sr., in 1845, and at later dates, namely, in 1853 and 1871. 
B. E. Cotting, M.D., Harvard, saw cases, and described them in papers 
read before local societies. (See Boston Medical and Surgical Journal, 
March 15th, 1873.) In 1874, Dr. Caleb Green, of Homer, Cortland County, 
N. Y., an accurate and intelligent observer, also witnessed an epidemic. 

An epidemic of this rare and interesting malady has recently prevailed 
in New York City, the first, so far as I am aware, in this locality. In 
a general practice of more than twenty years, extending over a consider- 
able portion of this city, I had previously observed nothing like it, and 
other older physicians having a large general practice, have informed me 
that they consider it an entirely new disease with us. Those who think 
that they have occasionally seen isolated cases of it previously to the 
recent epidemic, evidently refer to roseola. 

This epidemic of rotheln commenced in New York, near the close of 
1873, and attained its maximum prevalence in March and April, 1874, 
when it declined, occasional cases occurring throughout May. The first 
case which I observed occurred in the middle of December, in Seventy- 
first Street, being in the suburbs of New York, on the north. A few weeks 
later, cases were so numerous in the thickly settled portions of the city as 
to attract the attention of many physicians. It was evident that a disease 
had appeared with which we were not familiar, and as the eruption oc- 
curred in points, or small cii'cumscribed patches, it was, I think, usually 
designated by the physician, in want of a more accurate name, epidemic 
roseola, or was spoken of as a spurious measles. Those physicians who 
were familiar with foreign medical literature saw the resemblance between 
these cases and those of rotheln as described by British and continental 
observers, but in certain at least of the foreign cases the duration of the 
rash was said to be seven days (Liveing, Lancet, March 14th, 1874, and 
Medical News and Library, May, 1874), whereas in the cases in New York 
it commonly disappeared by the fourth day. But this discrepancy was 
not sufficient to invalidate the belief in the identity of the New York dis- 
ease with the foreign rotheln. It was readily explained by the difference 
in the seasons in which the cases occurred, for Liveing observed his cases 
in June and July, and the greater the external heat the longer the dura- 
tion of the eruption, as we will see. 

Between the middle of December and the 1st of May I had observed 
and treated this malady in eighteen families. Cases occurred in three 
other families living in the same houses with some of those which I attended, 
and as they were fully and clearly described to me, so that there could be 
no doubt as to their nature, I have included them in my statistics. Forty- 



186 ROTHELN. 

eight cases were observed iu the twenty-one families. During May, when 
the epidemic was declining, I saw six additional cases occurring singly in 
families, making a total of fifty -four. 

Age. Cases. 

From 8 months to 1 year, ........ 2 

" 1 year to 2 years, 4 

" 2 years to 5 " 16 

" o' " 10 " 23 

" 10 " lo " 3 

" 1-5 " 30 " 6 

Total, 54 

The age of the youngest patient was eight months, and that of the oldest 
thirty years. Seventy-two per cent, of the cases were between the ages of two 
and ten years, so that rotheln is pre-eminently a disease of childhood. In- 
dividuals in and beyond the middle period of life seem to have nearly an 
immunity from it. The age of the oldest patient of whom I have been in- 
formed, was about forty years. On March 25th, when I was on duty in 
the New York Catholic Foundling Asylum, rotheln occurred in a boy aged 
four years, following closely an extensive epidemic of measles among the 
inmates. In April, during the attendance of Drs. O'Dwyer and Reid, 
about thirty children were affected with it in this institution, while among 
the large number of female nurses and employes, who were chiefly between 
the ages of twenty and thirty years, all but three escaped. 

Premonitory Stage. — Premonitory symptoms are in most instances 
either absent, or so mild as to attract little attention. It not uufrequently 
happened in the New York epidemic, that the parents were first made 
aware of the sickness of their children by observing the eruption. In one 
or two instances in my practice, children were sent from school not because 
they felt too ill to remain, but on account of the unusual appearance of 
the skin. Commonly, however, iu those old enough to express their sensa- 
tions, a premonitory stage of some hours, or a day, or even of longer dura- 
tion was present, consisting of slight languor with headache, and sometimes 
nausea. Now and then patients vomited, previously to the eruption, as 
they frequently did during the first and second days of the eruptive stage. 
In only one instance did I observe grave prodromic symptoms. A boy, 
aged eight years, was suddenly seized with clonic convulsions, and while 
he was in the hot bath for the relief of these, the rash appeared along his 
back. 

Symptom.s. — Tegumentary System, (a) Skin — The eruption may ap- 
pear first upon the back as in the above case. In other instances it is first 
observed upon the chest or neck, and in others still upon the cheek or 
forehead. As in morbilli it travels downward, appearing after some hours 



SYMPTOMS. 187 

or a day upon the legs. It occurs upon all parts of the body unless upon 
the scalp and the palmar and plantar surfaces of hands and feet. The 
eruption in a majority of the cases which I have observed, gradually faded 
and disappeared, as already stated, by the fourth day. Children who were 
kept warm in bed, or in warm apartments, had it longer than others. In 
many instances traces of it were still visible when the patients were heated 
by exercise or excitement several days after recovery. A girl aged thirteen 
years, presented traces of it at times, though indistinctly, for three weeks. 
In most of the cases in the New York epidemic the rash commonly oc- 
curred in small circular patches, having nearly the size as well as color of 
those in morbilli, interspersed with which were numerous smaller erup- 
tions, scarcely more than points of the same color. Between these patches 
and points the skin presented the normal appearance, unless an occasional 
gooseflesh contraction. In exceptional instances the rash resembled that 
of scarlet fever, extending continuously over a considerable extent of sur- 
face. Thus in a boy of three years it presented so closely the appearance 
of the scarlatinous efflorescence over the trunk, that were it not that the 
temperature was constantly below one hundred degrees, and within three 
or four days all febrile movement had ceased, I would probably have con- 
sidered the malady a mild scarlatina. In certain patients the eruption, 
being in circumscribed patches and points, in the beginning like that of 
measles, becomes in two or three days confluent, so as to resemble the scar- 
latinous efflorescence, while over other parts the patches remain discrete. 
This was the character of the eruption upon the third and fourth days 
upon the extremities of a little boy in the Foundling Asylum. The rash 
is attended by considerable itching, disappears on pressure, produces slight 
roughness of the sui-face as ascertained by passing the fingers gently over 
it, and it usually disappears without desquamation. Exceptionally there 
is a slight branny exfoliation, and in one instance which I observed the 
exfoliation was as considerable over the abdomen as in cases of scarlatina. 
(b) Mucous Membrane. — In connection with the cutaneous eruption, a 
mild inflammation also occurs of the mucous membrane covering the fauces, 
buccal cavity and nostrils, and of the reflection of this membrane over the 
eyes and eyelids, namely, of the conjunctiva. In certain patients this in- 
flammation is scarcely appreciable, but in the majority it arrests attention 
at once. It produces more or less soreness of the throat, swelling of the 
tonsils, and even of the lymphatic glands in the vicinity of the tonsils, 
sneezing, and sometimes a slight discharge from the nostrils. It produces 
also a suffused, reddish, or weak appearance of the eyes, with a moderately 
increased lachryraation. On inverting the eyelids the palpebral conjunc- 
tiva is seen to be injected. In certain patients a moderate puriforra secre- 
tion collects at the inner angle of the eyelids. The eyelids are probably 
in most cases more or less oedematous, but the swelling is usually slight, 
and is apt to be overlooked by the physician. In three cases, which I now 



188 EOTHELN. 

recall, mothers have directed my attention to this oedema. In one of these, 
to wit, an infant of twenty-three months, there was so great tumefaction of 
the eyelids, commencing about the time when the eruption began to fade, 
that light was totally excluded from the eyes, and it was impossible to as- 
certain their condition. The skin covering the eyelids retained nearly its 
normal appearance, and the puriform secretion alluded to above, appeared 
between the lids. In three or four days the oedema of the lids, and the 
hypersemia of the conjunctiva rapidly declined. 

Pxdse — Temperature. — The largest number of accurate daily observa- 
tions relating to the temperature made during the epidemic in this city, 
were, I think, those of Dr. Reid in the Catholic Foundling Asylum during 
March. He has kindly furnished me his statistics relating to this symp- 
tom, as follows : " The number of closely observed cases in which the tem- 
perature was taken was twenty-four. In seventeen of the cases the tem- 
perature ranged from 97° to 99° ; in six it reached 100°, 100^°, and lOOf ° ; 
in one it reached 103^:° on the second day of the eruption, but remained so 
elevated only one day." In certain patients Dr. Reid observed what he 
designates " a tendency to the development of an ephemeral fever." These 
observations correspond closely with those made by myself in private prac- 
tice. Thus in sixteen cases I found the temperatures taken each day con- 
stantly between 98° and 100°, with a pulse under 110 per minute, except 
in one case in which it numbered 124. In certain other cases there was a 
more decided febrile movement, lasting from one to two or three days, oc- 
curring usually in the commencement. Thus a girl aged three and a half 
years had a temperature of 101|° and a pulse of 128. In another case the 
pulse was 124 and temperature 102°, In another, a girl aged three and 
a half years, there was active febrile movement on Saturday night, occur- 
ring without apparent cause. This abated on the following day, and she 
seemed well till Tuesday, w'hen the febrile movement returned, and the 
eruption appeared. On Thursday the temperature from 102° to 103° 
fell to 992°, and within a day or two she was convalescent. In two other 
patients from two to four days after the disappearance of the eruption, au 
accession of fever occurred, lasting about one day, and attended by com- 
plaint of pain or distress in the epigastric region, but without vomiting or 
diarrha^a. In one of these the temperature was 1034° and the pulse was 
130 per minute; in the other case temperature and pulse did not seem to 
be below these figures, but they were not accurately ascertained. Occa- 
sionally in the New York epidemic the febrile movement was obviously 
due more to complications than to the primary disease. Thus in two cases 
which I observed the febrile movement was mainly attributable to mild 
diphtheritic inflammation which had attacked the fauces. 

The observations therefore of Dr. Reid in the Foundling Asylum and 
my own in private practice, show' that the febrile movement is constantly 
mild in most cases of uncomplicated rcithelu, but that certain patients 



COMPLICATIONS NATUEE. 189 

have temporary exacerbations of fever in which the temperature is as 
elevated as in scarlet fever or severe measles. 

Respiratory System. — The mucous membrane of the larynx, trachea, and 
bronchial tubes does not participate or participates but slightly in the in- 
flammation which involves the nasal, buccal, and faucial surfaces. A 
large proportion of my patients had no cough whatever, but others had 
an occasional slight cough. A few had a cough commencing so long pre- 
viously that it was evidently accidental and not a symptom. 

Digestive System. — The tongue in rotheln is moist and of normal appear- 
ance, or covered with a slight fur. The appetite is impaired but not lost, 
there is a little or no thirst and the bowels are regular. Nausea is a com- 
mon symptom both during the premonitory stage and in the period of the 
eruption. Vomiting was present in several cases which I observed as one 
of the first premonitory symptoms ; in certain patients it occurred like- 
wise on the first or second day of the eruption. In other patients there 
was no nausea so far as could be ascertained, either immediately before, 
or during the disease. This symptom is less common in rotheln than in 
scarlet fever, but is as common apparently as in morbilli. Foreign ob- 
servers have occasionally remarked the presence of albumen in the urine 
of patients affected with rotheln. I am not aware that it was observed in 
the New York epidemic, but I think that the urine was seldom examined 
by the appropriate tests. I made the examination in three different cases, 
but found no albumen unless a slight trace in one. 

Complications — PpvOgnosis. — The only complications which occurred 
in my cases were those already alluded to, namely, mild diphtheria in two 
patients. Diphtheria being at the time prevalent, the diphtheritic inflam- 
mation occurred by preference upon those faucial surfaces which were 
already the seat of inflammation. We see the same preference in cases of 
scarlet fever and measles. In the Foundling Asylum varicella compli- 
cated one case and pneumonia another. In a third case pneumonia ap- 
peared three days after the disappearance of the eruption. The prognosis 
in rotheln is very favorable. Patients do not die from the severity or de- 
pressing effect of the disease, as we observe in cases of scarlet fever, and 
with the exception of diphtheria there does not seem to be in it any tend- 
ency to the development of complications. 

Nature. — Is rotheln a malady per se, or is it a malady with which we 
have been familiar under another name, but whose form and character 
are modified by unusual meteorological conditions? Most of the cases in 
the New York epidemic bore considerable resemblance to cases of morbilli, 
both as regards the appearance and duration of the eruption, and the 
mucous inflammations. Parents often diagnosticated measles before the 
arrival of the physician, and the physician himself at first glance some- 
times made the same diagnosis. But in rotheln the shortness and mild- 
ness of the premonitory stage, lack of uniformity and certain peculiarities 



190 ROTHELN. 

of the eruption already pointed out, absence of bronchitis and general 
mildness of symptoms, with uniform favorable prognosis, afford a strong 
contrast with measles. But the decisive proof that rotheln is not a modi- 
fied measles is found in the fact that the one does not prevent the occur- 
rence of the other. Of the forty-eight cases observed by myself prior 
to May 1st, nineteen at least had had measles, and one who had rotheln 
took measles a month subsequently, I have already stated that in the 
Foundling Asylum rotheln closely followed an epidemic of measles. A 
considerable number of the children affected with the former disease had 
recently recovered from the latter. 

That rotheln is not a form of scarlet fever is evident from the fact that, 
as regards at least the New York epidemic, the rash was in most instances 
quite different from the scarlatinous efflorescence, occurring, as we have 
seen, in small more or less circular points and patches. Moreover, there is 
in rotheln a slight febrile movement and general mildness of symptoms 
quite unlike what we observe in scarlatina; or if there is a considerable 
febrile movement, it has a short duration. But the conclusive proof of an 
essential difference between these two diseases, is found in the fact already 
stated in regard to measles, namely, that an attack of the one malady 
does not prevent the occurrence of the other. There are, it is true, cases 
in which it is difficult to make the differential diagnosis between rotheln 
and mild measles or mild scarlatina at first, but when the course of the 
malady has been closely observed for three or four days, it rarely happens 
that we are unable to make out its character. 

The first cases of rotheln observed in the New York epidemic were 
often, as I have stated, designated by the name epidemic roseola by the 
physicians who were called to treat them, since they were ignorant of their 
true nature, and in want of a better name. But rotheln differs so widely 
from the peculiar form of dermatitis known as roseola, that it may be 
properly said to have no kinship with it. The successive occurrence of the 
eruption in rotheln over the upper and then the lower part of the body, 
but covering the whole surface, its definite duration of three to five days, 
its size, usually larger than that of roseola, are points of difference. More- 
over, roseola would not, without so great a change in its character as to 
become virtually a distinct disease, occur in the cool months, without any 
appreciable dietetic cause, as an epidemic over a certain area, and for a 
limited time, affecting whole households of children, and sparing other 
households as well as individuals of a certain age. We, therefore, con- 
clude that rotheln, though presenting certain resemblances to roseola, as 
well as to measles and scarlet fever, is a disease i^er se. 

The cases of an epidemic malady, which occur when its causes or condi- 
tions are most strongly operative, and Avhich are at this time apt to be 
typical, obviously afford the best data for studying its nature. Such were 



NATURE. 191 

the forty-eight cases which I observed. In thirteen of the twenty-one 
families, the first cases were children who, up to the time of the seizure, 
were attending the public or private schools, and in certain instances those 
who were nearly simultaneously attacked, living perhaps in streets widely 
apart, were attending the same school. We see in this a close resemblance 
to 'the mode in which those common exanthematic diseases of childhood, 
which are universally admitted to be contagious, as scarlet fever and 
measles, spread in a community. It is largely through the schools that 
these diseases are introduced into families. 

In most of the families containing two or more children, the cases were 
multiple, not occurring simultaneously but in succession, as if the malady 
were contracted from the one first affected. This is what we daily witness 
in the spread of the exanthematic fevers. - In the first of the above fami- 
lies, to wit, Mr. E 's, a girl attending one of the public schools takes 

rotheln in the middle of December. The two remaining children sicken 
with it, one week and two weeks later. A niece visiting in the family at 
the time when the first child was sick, but returning home to another street 
soon after, also has the eruption on December 27ih. Alice R., aged ten 
years, a frequent visitor at Mr. E 's, living in the same street and sev- 
eral times exposed to his children during their sickness, takes rotheln about 
January 4th. West Seventy-first Street, where this family resided, is 
suburban and thinly settled, and I could not learn of other cases in that 
locality. 

These facts and cases seem to me to demonstrate the contagiousness of 
rotheln, at least during the time in which the conditions are most favor- 
able for its development, or during the time in which the epidemic influ- 
ence is most pronounced. During the declining period of the New York 
epidemic, the cases which I observed, as they occurred singly and without 
known exposure, lent no support to the theory of contagiousness. 

From facts and observations like the above, we infer that rotheln is 
one of the exanthematic fevers. It resembles varicella in general mildness 
of symptoms, in the absence of dangerous complications or sequelae, and in 
the uniformly favorable prognosis, while its symptoms and history show 
its close alliance with measles and scarlet fever. If this view is correct, 
we must believe that it possesses an incubative period, which in the cases 
detailed above apparently varied between seven and twenty-one days. 
The incubative period, therefore, resembles that of scarlet fever, which, as 
is well known, is very unequal in different instances. 

Rotheln, like varicella, requires little treatment. I commonly gave 
small doses of quinine to my patients. 



192 VARIOLA. 



CHAPTER IV. 

VARIOLA — VARIOLOID. 

Variola, or small-pox, is a specific febrile affection, accompanied by 
a vesiculo-pustular eruption of the skin. Since the discovery of the pro- 
tective power of vaccination it has been shorn of much of its terror, but 
it is still the most loathsome and most dreaded of all the fevers. Two 
forms of this disease are recognized, depending on the fact whether there 
has been previous vaccination. If the patient has been vaccinated at 
some period in his life, the disease, which is rendered milder in conse- 
quence, is designated varioloid. If there has been no vaccination, it is 
called variola or small-pox. Both forms are identical in nature, the one 
communicating the other; they differ only in gravity. 

Small-pox presents four stages : the initial, or that of invasion ; the 
eruptive ; that of desiccation ; and, lastly, that of desquamation. It is 
called discrete when the pustules remain separated from each other ; con- 
fluent when they unite. This division is made according to the character 
of the eruption upon the face and hands. There are parts of the surface, 
as the abdomen, where the pustules are always discrete, even in the con- 
fluent form. 

Incubative Period. — During the last half of the last century inocu- 
lation with variolous matter was extensively practiced in Great Britain 
and on the Continent, as it was found that small-pox thus communicated 
Avas milder than when received by infection. This operation enabled 
physicians to determine the period of incubation, which was found to be 
from eight to eleven days. When variola is communicated through the 
air, the incubative period is somewhat longer, namely, from twelve to 
fourteen days. 

Stage of Invasion. — Small-pox begins abruptly with chilliness. In 
children of an advanced age there is often, as in the adult, a distinct 
chill. This is followed by fever and such symptoms as usually accom- 
pany febrile movement, namely, lassitude, anorexia, and thirst. There 
are, in addition, symptoms which, though not peculiar to small-pox, are 
so marked in the commencement of this disease, that they possess con- 
siderable diagnostic value. These symptoms pertain to the nervous sys- 
tem. There are in most cases of varioloid as well as variola, in the 
initial stage, severe frontal headache, pain in the small of the back, and 
great drowsiness, sometimes with delirium. In many children convulsions 
occur, preceded and followed by a degree of stupor which is almost as 



STAGE OF ERUPTIO]Sr. 193 

profound as coma. Trousseau suggests the name rachialgia for the pain 
in the back, as he believes that it is located in or around the spinal cord. 
This belief is based on the fact which he, as well as other observers, has 
noticed, that there is sometimes in connection with this symptom an in- 
complete paraplegia, indicated by numbness of the legs, or even inability 
to use them, and sometimes more or less paralysis of the bladder. These 
paraplegic symptoms pass off in a few days. Vomiting is also a common 
symptom in this stage, and one also of diagnostic value. It occurs at 
short intervals for twenty-four to thirty-six hours. The same symptom is 
common in scarlet fever, and not infrequent in measles, but in both these 
affections irritability of stomach is much less persistent than in small-pox ; 
vomiting does not occur in normal rubeolous and scarlatinous cases more 
than once or twice. 

The tongue is covered with a moist fur. If the disease is to be discrete, 
constipation is commonly present in the stage of invasion; if confluent, 
diarrhoea is a common symptom, continuing till the fourth or fifth day, or 
even longer. Roseola or erythema sometimes occurs in this stage^ and 
this may lead to error of diagnosis, the disease being mistaken for one of 
these cutaneous affections, or even for scarlet fever. The symptoms in 
the stage of invasion are usually more violent in confluent than in discrete 
variola, but there are exceptions. 

Stage of Eruption. — The eruption commences about the third day, 
earlier in some cases, later in others. The average duration, therefore, 
of the first stage is somewhat shorter than in measles, but considerably 
longer than in scarlet fever. Sydenham has stated, and observations 
show the truth of the remark, that the shorter the first stage, the more 
severe the disease will prove to be ; and, conversely, the longer the period, 
the milder will be its form. Therefore, if the eruption begins on the 
second day, it will, as a rule, be confluent ; if not till the fifth or sixth 
day, it will be scanty and the disease light. 

The eruption commences in minute red spots, somewhat like those of 
lichen, which gradually enlarge. It is first observed around the lips and 
upon the neck, then upon the face, scalp, upper part of chest, arms, and 
finally upon the lower part of the chest, the abdomen, and legs. It is 
sometimes, especially in young children, first observed in the folds of the 
skin, as about the genitals or in the groin. If the cuticle is irritated, 
as by a sinapism, the eruption often appears first upon this part of the 
surface and in greater abundance than elsewhere. The eruption com- 
mencing in a minute reddish point, as stated above, rapidly enlarges, and 
soon its central part begins to be indurated and raised. It feels round 
and hard to the finger, is tender, and its diameter does not ordinarily 
exceed two lines. This is the papular stage. The papulre increase and 
become more elevated, and in twenty-four to forty-eight hours from the 
commencement of the eruptive stage they become vesicular. On the fifth 

13 



194 VARIOLA. 

day of the eruption, or eighth of the disease, the vesicle has attained its 
full size. Its diameter is then about one-fourth of an inch, and its eleva- 
tion is two or three lines. Its base is circular and indurated, and it is 
surrounded by a narrow zone of inflammation, indicated by redness and 
tenderness of the skin. The pock commonly, as it passes from the papu- 
lar to the vesicular stage, loses its acuminate form, and becomes depressed 
in the centre, but in most cases, mixed with the umbilicated vesicles, are 
some which remain acuminate. 

In proportion as the eruption becomes developed in discrete variola and 
in varioloid, the symptoms which accompanied the stage of invasion abate ; 
the fever, headache, pain in the back, and thirst cease, and the appetite 
returns. In the confluent form, the febrile action continues with little 
abatement. 

Simultaneously with the eruption upon the skin, an eru])tion also occurs 
upon the buccal and faucial surface, and often upon that of the air-pas- 
sages. It occurs sometimes, also, upon the conjunctiva, producing dan- 
gerous ophthalmia, and even ulceration, with loss of sight, and upon the 
mucous surface of the genital organs. The form which it presents upon 
mucous surfaces is somewhat different from that upon the skin. There is 
at first a deposit of fibrin, producing a small, round, grayish spot at the 
point of eruption — firm, slightly elevated, and covered, if not by the entire 
mucous membrane, at least by its epithelial layer. Ulceration soon occurs, 
as in ulcerous stomatitis, and, if the patient live, the reparative process 
succeeds, as in simple ulcers. The eruption upon mucous surfaces increases 
considerably the suffering of the patient, in consequence of the tenderness 
of the ulcers ; and if its seat be the surface of the larynx or trachea, it 
may be the immediate cause of death, especially in young children, by 
obstructing respiration. 

The cutaneous eruption has been traced to the vesicular stage. On or 
about the fifth day of the eruptive period, or eighth of small-pox, the 
vesicles gradually change their character, their contents becoming thicker 
and turbid. At the same time they increase somewhat in size, and the 
central depression disappears. This is designated the stage of maturation, 
or of suppuration, though it is known that the turbidity is due chiefly to 
another substance than pus. The pock having undergone these changes, 
is termed the pustule. 

In discrete variola^ and in varioloid, the fever returns during the pus- 
tular stage; or, if the form of the disease is confluent, and the fever has 
continued,, it now becomes more intense. The return of fever, or its in- 
crease, is denoted by increased frequency of pulse, elevation of tempera- 
ture, dryness of skin, anorexia, and thirst. A tendency to constipation 
remains throughout the disease in varioloid and discrete variola ; in the 
confluent form, diarrhoea more frequently occurs, which, if it continue, is 
an unfavorable prognostic sign. 



STAGE OF DESICCATION. 195 

Other changes occur. The pustules increase somewhat in size, and be- 
come more globular. Some of them, when most distended, break through 
friction of the clothes, or scratching of the child, and, their contents 
escaping, add to the loathesomeness of the disease. There is in the pus- 
tular stage more or less redness of the surface between the eruptions, and, 
except in the mildest cases, there is tumefaction from subcutaneous infil- 
tration. In the confluent form, at this period, the features are often so 
swollen that the friends would not recognize the patient. The eyelids may 
be so oedematous that the eyes are for a time concealed from view. ' This 
oedema of the surface is not altogether absent in the vesicular stage, but it 
increases during the time of maturation, after which it subsides. 

Stage of Desiccation. — This immediately succeeds the full develop- 
ment of the pustules. The liquid portion of the contents of the pustules, 
which are broken, evaporates, leaving a crust. If there is no rupture, the 
liquid is absorbed, and a scab results, which, though smaller, preserves in 
a measure the form of the pustule. While the pustule desiccates, the sur- 
rounding inflammation rapidly abates. The crusts occur first upon the 
face, and on other pai'ts in the order in which the eruption appeared. The 
odor from the patient, at this time, is peculiar. In the confluent form, 
especially, it is very offensive, and can be noticed at a distance from the 
bedside. Rilliet and Barthez call it nauseous and fetid. As desiccation 
progresses, the symptoms, local and general, abate. The pulse and tem- 
perature, if the case is favorable, return to their normal standard. The 
cough, hoarseness, and thirst disappear, while the appetite returns ; the 
sleep is more tranquil, and the functions, generally, are more regularly 
performed. 

The last stage is that of desquamation ; it commences between the 
eleventh and sixteenth days. The scabs, which present a dark or brown- 
ish appearance, are successively detached. This period lasts several days ; 
sometimes two or three weeks even elapse before all the crusts separate. 
In the meantime the patient gradually recovers his health and former 
strength. After the fall of the crust, the cicatrix underneath presents a 
reddish appearance. This color gradually fades, and there remains an 
irregular depression, or pit, of a lighter color than the surrounding sur- 
face ; and if there has been a full development of the eruption, disfigur- 
ing the patient for life. 

Such is the clinical history of variola, when it is favorable, and its course 
is regular. The disease is sometimes irregular. In rare instances the 
eruption occurs almost at the commencement of the attack. The form is 
then very apt to be confluent. There are irregularities, also, in consequence 
of diarrhoea, hteraorrhages, or other complications. I have known the 
eruption appear first on the limbs, and last on the trunk and face, and the 
appearance of the eruption is not always the same. In the ana;mic and 
feeble child it often presents a pale color, with some induration at its base, 



196 VARIOLOID. 

but without the red areola around it, or with this quite indistinct. In rare 
instances the vesicles have a reddish color, their contents being tinged with 
blood. This form of variola is designated htemorrhagic. It indicates a 
profoundly altered state of the blood. The eruption in this form is of 
small size, and if the pock is broken, blood oozes from it. 

Varioloid. — The course of varioloid is similar to that of variola, but 
it is somewhat shorter. It commences with rigors, followed by fever, head- 
ache, pain in the back, vomiting, drowsiness, and sometimes delirium, or 
even convulsions. The symptoms in the stage of invasion are, indeed, the 
same in character, and often nearly as severe as in variola. With the initial 
symptoms, there is also sometimes a scarlatiniform eruption, so that the 
disease may at first be mistaken for scarlatina. On the third or fourth 
day the variolous eruption commences. The number of pocks is commonly 
few, often not more than twelve to twenty. In the mildest form of vario- 
loid, if the physician is not summoned in the stage of invasion, he is not 
apt to be called at all, so that the patient may pass through the disease in 
ignorance of its nature. I have known this occur, the true character of 
the affection not being ascertained till others were affected, either with 
variola or varioloid. 

The eruption pursues a more rapid course in varioloid than in the un- 
modified disease. By the fifth or sixth day the pustules are fully de- 
veloped, though often smaller and less likely to be ruptured than in 
variola. Often, in varioloid, the eruption aborts. It remains papular two 
or three days, and then declines, or it may reach the vesicular stage, and 
decline without pustulation. 

The constitutional symptoms in varioloid abate with the commence- 
ment of the eruptive stage. The secondary fever is slight or absent. 

Such is the usual mild course of varioloid, but not always. If several 
years have elapsed since the vaccination, its protective power is greatly im- 
paired, and varioloid may then exhibit as severe a form as ordinary small- 
pox. In some instances it is fatal. 

The term varioloid is, as has been stated, applied to cases of variolous 
disease where there has been previous vaccination. It is also applied by 
writers to second attacks, whether the first occurred from infection or from 
variolous inoculation, but such cases are rare. 

Mode of Death. — Death in small-pox occurs in several different ways. 
The most fatal period is the pustular stage. Feeble children not unfre- 
quently die from exhaustion at or about the time that the pustules attain 
their greatest size. The eruption appears and becomes developed as usual, 
but there are evidences of weakness in the patient, and suddenly the prog- 
ress of the vesicle or pustule ceases. It begins to subside, and its walls 
shrivel. There is evidently absorption, in part, of the liquid contents. 
These phenomena are of the gravest character. Death is the common 
result, and within twenty-four hours. In other cases death occurs from 



ANATOMICAL CHAEACTERS. 197 

apnoea. The pock increasing in size in the larynx and trachea, obstructs 
inspiration, or there may be the formation of a pseudo-membrane, as in 
true croup. This is not an unusual mode of death in young children, in 
whom the calibre of the larynx and trachea is small. Sometimes convul- 
sions and coma occur in the last houi-s of life. In other cases the stage of 
desquamation is reached, but convalescence does not occur. The patient 
each day becomes more anaemic and feeble, and finally death results from 
failure of the vital powers. Again, after small-pox has run its course, 
purpura hseraorrhagica may be developed. Haemorrhages occur from 
the gums, throat, nostrils. Blood is vomited, and evacuated in the stools. 
I have known death to occur in all these ways, but that from purpura is 
least frequent. Sometimes, as in scarlet fever, death occurs suddenly and 
unexpectedly in confluent, and even in discrete variola, when the previous 
symptoms had apparently been favorable. The patient is overpowered by 
the intensity of the virus. 

Anatomical Characters. — In those who have died of variola, with- 
out inflammatory or other complication, the heart-clots have been found 
small, dark, and soft. The blood is dark and thin. The vessels of the 
brain and its membranes are injected, so that numerous red points appear 
on the cut surface of this organ. The vessels of the lungs and the ab- 
dominal organs are congested, while the muscles present a deep red color. 
The variolous eruption penetrates more deeply than that of any other 
exanthematic fever. It has been stated elsewhere that it occurs not only 
on the skin, but often on the surface of the mouth, fauces, and air-passages. 
The mucous membrane in these situations is frequently also the seat of 
catarrhal inflammation, being thickened and softened, and in some parts, 
as the larynx, a pseudo-membrane is occasionally produced, as in croup. 
The inflammation, whether catarrhal or pseudo-membranous, may occur 
without as well as with the presence of the specific eruption. 

The eruption very seldom, perhaps never, appears upon the gastro-intes- 
tinal surface, but the solitary follicles and patches of Peyer are often en- 
larged, as in some other zymotic affections. The liver, spleen, and kidneys 
are commonly congested in those who have died of variola. The spleen, 
especially, is increased in volume and softened ; the kidneys are enlarged, 
as if from commencing nephritis, and sometimes softened. 

The minute structure of the pock is described by Rilliet and Barthez, 
and others. The vesicle is multilocular, consisting of at least five or six 
compartments, with distinct partitions. Its centre is united by fibrous 
bands to the derm beneath, which union gives rise to the umbilicated ap- 
pearance. The giving way of these minute bands in the pustular stage 
occurs when the form changes from the umbilicated to the convex. In the 
pustular stage also, according to some, a fibrinous formation occurs within 
the pustule ; according to others, this substance is of the nature of the 



198 VARIOLOID. 

epidermis, presenting the appearance of the cuticle when macerated. 
Mixed with this epidermic or fibrinous formation are pus-cells. 

Complications. — There are several different complications of variola 
One is salivation. This is common in the adult, but rare in the child. 
When it occurs in the child, it is slight, commencing with or about the 
time of the eruption, and disappearing in from one to four or five days. 
Ophthalmia is another complication. vSimple conjunctivitis, often quite 
intense, may occur in consequence of pustules developed under the lids. 
This inflammation subsides Avithout injury to the eye, as the primary dis- 
ease abates. A more serious inflammation occurs at an advanced stage 
of the disease, commencing in or near the desquamative period. This 
produces more or less chemosis, and sometimes opacity or ulceration of 
the cornea. A similar inflammation may occur in the ear, giving rise to 
otorrhoea, and even in some patients to rupture of the drum of the ear. 
Abscesses in the subcutaneous connective tissue have been occasionally ob- 
served, especially in the confluent form. Subcutaneous infiltration and 
feebleness of constitution favor their occurrence. Suppuration Avithin the 
joints is a somewhat rare complication or sequel, rendering convalescence 
protracted, if, indeed, the case is not fatal. 

M. Beraud has published a memoir to show that orchitis in the male, and 
ovaritis in the female may complicate variola. These inflammations are 
believed to be accompanied by a small and imperfect variolous eruption 
upon the tunica vaginalis and the peritoneal covering of the ovary. Trous- 
seau states that he has often met this complication in the male, since his 
attention was called to it. It is mild, and subsides with the disappearance 
of the eruption. Laryngitis, simple or diphtheritic, bronchitis, pneu- 
monia, pharyngitis, purpuric haemorrhages, gangrene of the mouth or 
other parts, oedema pulmonum, and oedema glottidis are occasional com- 
plications, some of which are frequent, others rare. 

Prognosis. — This depends on the age, vigor of system, form of the 
disease, and the presence or absence of complications. The younger the 
child, the greater the danger. Trousseau says: "Confluent variola, and 
even discrete variola, are almost always fatal in individuals less than two 
yeai-s old." Above the age of three or four years discrete variola usually 
ends favorably, but the confluent form is still, as a rule, fatal. Varioloid 
in the child is a mild disease, terminating favorably in a large proportion 
of cases. It is milder at this age than in the adult, on account of the 
more recent period of vaccination, and if a case of supposed varioloid is 
severe, and the eruption abundant, it is probable that the vaccination was 
spurious. 

It is not necessary, from what has been said, to specify the favorable 
prognostic signs. The unfavorable prognostics are, great violence of the 
initial symptoms ; early appearance of the eruption ; an abundant erup- 
tion, especially if pale, and without swelling of the surface ; rapid decline 



TREATMENT. 199 

of the eruption in the vesicular or pustular stage ; hsemorrhagic eruption, 
or hsemorrhages from the surfaces ; fever continuing after the appearance 
of the eruption ; diarrhoea persisting beyond the third or fourth day ; de- 
lirium or great drowsiness ; a frequent and feeble pulse ; and, finally, ob- 
structed respiration — if slow, indicating a pseudo-membrane or variolous 
eruption in the larynx or trachea ; if rapid, indicating bronchitis or 
pneumonia. 

DiAGKOSis. — The diagnosis cannot be made with certainty prior to the 
eruptive stage. If, however, small-pox is prevalent, if the patient has not 
been vaccinated, and the symptoms which pertain to the period of inva- 
sion are present, as headache, pain in small of back, repeated vomiting, 
drowsiness, and perhaps convulsions, there is ground for the gravest sus- 
picion. If, in addition to these symptoms, reddish points begin to appear 
on the second or third day, the diagnosis may be made with confidence. 
At this early period, even before there is any distinct cutaneous eruption, 
ash-colored spots may sometimes be observed on the buccal or faucial sur- 
face, the commencement of the variolous eruption ; these possess consider- 
able diagnostic value. 

The scarlatiniform efilorescence, in the first stage of variola, sometimes 
leads to the belief that the disease is scarlet fever. The absence of the 
pharyngitis, and the appearance of the variolous eruption soon after the 
efflorescence, correct the diagnosis. Small-pox has, in the beginning of the 
eruptive period, sometimes been mistaken for measles. The points involved 
in the differential diagnosis have been presented in treating of that disease. 
After the development of the eruption, it may be mistaken for varicella. 
The eruption of varicella is, however, preceded by symptoms which are 
milder and of shorter duration, and its appearance is different. It is 
irregular, instead of round ; is not umbilicated, and it does not have the 
found, inflamed, and indurated base, which characterizes the variolous 
eruption. The eruption of ecthyma is sometimes umbilicated, but the 
symptoms of ecthyma and variola, and the progress of the eruptions in 
the two diseases, are very different. 

Treatment. — Small-pox, like the other essential fevers, is self-limited, 
and therefore the constitutional treatment should be sustaining and pallia- 
tive. In the first stages of the disease, the diet should be simple ; gentle 
laxatives and refrigerant drinks are required if there is much febrile ex- 
citement. Lemonade is a grateful drink, and may be given in moderate 
quantity. Spiritus Mindereri in carbonic acid water may be allowed. As 
the disease advances, more nutritious food should be recommended ; and 
in severe cases carbonate of ammonia, and even alcoholic stimulants, are 
refjuircd. 

As confluent sniall-pox is nearly always, and the discrete form often, fatal 
in infancy, the physician should carefully watch the progress of the case 
in the infant. By judicious treatment, some, in this period of life, may be 



200 VARIOLOID. 

saved, who otherwise would perish. In the iufaut depressicg measures 
should be avoided, A laxative may be given, at first, if there is much 
fever, and the bowels are constipated ; but the diet should be nutritious, 
and many soon require tonics and stimulants. If the pulse become more 
frequent and feeble, or if, with frequency of the pulse, the face and ex- 
tremities become cool; or if, in the vesicular or pustular stage, the erup- 
tion suddenly subsides, alcoholic stimulants must be immediately employed, 
or the patient dies. 

Such is an outline of the constitutional treatment required in small-pox. 
Sydenham inculcated a mode of treatment which experience has shown to 
be injurious in infancy and childhood. He had observed that the severity 
of the disease was ordinarily proportionate to the amount of eruption, and 
concluded from this fact that measures which retarded the development of 
the eruption were salutary; cold drinks, a cold apartment, scanty covering 
of the body, cathartics that caused derivation of blood from the surface, 
even sometimes the abstraction of blood, were considered according to 
Sydenham's theory, to be useful as means of preventing full development 
of the eruption, 

Sydenham's treatment, however appropriate it might sometimes be in 
ease of robust adults, is unsuitable for children, because they do not, as a 
rule, tolerate, in this disease, measures which reduce the strength. More- 
over, small-pox is rendered more dangerous by what Rilliet and Barthez 
designate perturbating treatment — treatment which renders it abnormal. 
The regular appearance and development of the eruption are requisite in 
order that the case may progress favorably. On the other hand, the op- 
posite plan of treatment, which families, if left to themselves, are apt to 
adopt — namely, the employment of measures to promote pei'spiration, as 
hot drinks, and confinement in a heated room — is also injurious. 

The patient should be kept in a temperature such as he has been accus- 
tomed to, and such as is agreeable to him ; his diet should be simple and 
nutritious; laxative medicine should only be given to procure the natural 
evacuations. In small-pox, as in all infectious diseases, free ventilation of 
the apartment is required. 

While the general eruption in small-pox should not be interfered with, it 
is proper to endeavor to diminish, so far as possible, the size of the pocks, 
on parts exposed to view, so as to prevent disfigurement. Professor Flint, 
in his Treatise on the Practice of Medicine, has published an excellent sum- 
mary of the various measures which have been recommended for accom- 
plishing this end. First : The opening and breaking up of the vesicle by 
means of a fine needle. This is tedious practice in confluent variola, but 
it can readily be performed in the discrete form — at least as regards the 
vesicles upon the face. This treatment was proposed by Rayer, and it is 
recommended by many who have tried it. Secondly: After the evacu- 
ation of the liquid, the cauterization of the vesicle by a pointed stick of 



TREATMENT. 201 

nitrate of silver. Rilliet and Barthez say, in reference to this mode of 
treatment, " Individual cauterization of the pustules is, on the other hand, 
an almost infallible means of causing them to abort. To be successful, it 
is necessary to penetrate into the interior of the pustule with a pointed 
crayon of nitrate of silver, in order to cauterize the derm. ... It is only 
the first or second day of the eruption that it (cauterization) has certain 
success; nevertheless, we have often seen it succeed the third or the fourth 
day, or even the fifth." 

Thirdly : The application of tincture of iodine once or twice daily over 
the eruption when in the papular stage. Some writers, who have em- 
ployed iodine, state that it does not prevent pitting, but diminishes it. Its 
favorable effects are produced by coagulating the contents of the papule. 
Foui-thly: The exclusion of light and air by means of a plaster. A mix- 
ture containing tannate of iron has been employed for this purpose in one 
of our hospitals. This produces a black mask. Light and air may also 
be excluded by smearing the face with sweet oil, and dusting twice daily 
upon the oiled surface a powder containing equal parts of subnitrate of 
bismuth and prepared chalk. Fifthly: The application of mild mercurial 
ointment upon the face or other parts of the surface, where it is desirable 
to render the eruption abortive. This mode of treatment -does diminish 
the size of the vesicles and the pitting, but I should not recommend it for 
children. I have known in the adult severe mercurialization from its em- 
ployment for four or five days, and, though young children do not exhibit 
so readily the effects of mercury, the use of the ointment, unless for a very 
limited period, increases, in my opinion, their feebleness, and diminishes 
the chance of their recovery. Calamine made into a paste with sweet oil 
is said to be equally effectual with mercurial ointment, and it produces no 
constitutional effect. Its effect is obviously similar to that of the bismuth 
and chalk employed with sweet oil as stated above. Of late, I have em- 
ployed pulverized charcoal made into a thin paste with sweet oil or glyc- 
erin, and applied daily or twice daily to the face. It effectually ex- 
cludes the light, and the result has been so good as regards pitting, that I 
shall continue to use it. Curschmann recommends as preferable to any of 
these methods, the use of iced compresses to the face and hands. The pain, 
redness, and swelling are diminished by their use, but without change in 
the copiousness of the eruption. {Ziemssen's Encydop.) If fissures or 
excoriations occur, an application may be made of oxide or carbonate of 
zinc in glycerin, one drachm to the ounce. 

The prevention of small-pox, so far as practicable, is one of the import- 
ant incidental duties of the physician. Isolation of the patient, and pre- 
cautions in reference to his clothes and bedding, are imperatively required, 
so great is the infectiousness of this disease. The only certain means of 
prevention is confessedly vaccination, and providentially the incubative 
period of the vaccine disease is much less than that of variola. Therefore, 



202 VACCINIA. 

small-pox may be prevented after the virus is received in the system, by 
timely and successful vaccination. Vaccination, at any period between 
the time of exposure and the commencement of the symptoms of invasion, 
will either prevent the occurrence of small-pox or modify it. If the symp- 
toms of invasion have already commenced, it is uncertain whether it pro- 
duces any modifying effect. 



CHAPTER V. 

VACCINIA. 

Vaccinia is a mild eruptive disease, which occasionally occurs among 
cattle, and has been propagated from them to man. It is characterized by 
the appearance upon the surface of one or more papules, which soon be- 
come vesicular, and then pustular. It is communicable by contact, but, 
unlike the other eruptive fevers, it is not contagious through the air. It 
is inoculable, both by the liquid contained in the vesicle, which is desig- 
nated vaccine lymph, and by the scab which results from the desiccation 
of the pustule. 

To Gloucestershire, England, the honor belongs of discovering and 
popularizing the fact that vaccinia, a mild and comparatively harmless 
disease, is transmissible from the cow to man, and that it affords protection 
from small-pox. It appears that a vague opinion prevailed among the 
farmers of this dairying section, that a disease, which has since been desig- 
nated vaccinia, was occasionally received from the cow in milking, the 
virus passing from a pustule on the teat to a sore or chap on the hand of 
the milker, and that those who thus Contract the disease receive immunity 
from small-pox. As usually happens with important discoveries, so dull 
of apprehension is human intellect, these people, to whom Providence had 
revealed so important a fact, were blind to its real value. Finally, in the 
year 1774, Benjamin Jesty, whom the world has not sufficiently honored, 
"an honest and upright man," according to his epitaph, a farmer of Glou- 
cestershire, had the courage to vaccinate his wife and two children. His 
excellent moral character did not shield him. He was regarded by his 
neighbors as an inhuman brute, who had performed an experiment on his 
own family, the tendency of which might be to transform them into beasts 
with horns. 

The first essay in vaccination appears to have been entirely successful, 
but the prejudice against the operation continued. A fifth of a century 
passed, during which there was no extension of the benefits of this great 
discovery. At last, towards the close of the last century, Dr. Edward 



I 



VACCINIA. 203 

Jenner, a physician of Gloucestershire, and inoculator of his district, began 
to investigate this disease of the cow, about which little was known, and 
the grounds for the belief that it afforded protection from small-pox. For- 
tunately for the world, Jenner had been educated under John Hunter, 
and had learned from his great master to study nature rather than books, 
to be guided by experience and observation rather than by the dogmas 
of his predecessors or of the schools. 

Jenner performed his first vaccination on the 14th of May, 1796, twenty- 
two years after Benjamin Jesty had lost his good name among his neigh- 
bors for vaccinating his own family. The popularizing of vaccination, 
mainly through Jenner's perseverance, affords one of the most interesting 
and instructive chapters in the history of medical science. How he went 
up to Loudon, full of the importance of the discovery, and was there 
advised by his medical friends to desist from his wild schemes, lest he should 
injure the reputation which he had gained by publishing a creditable 
paper on the cuckoo ; how he was allowed to vaccinate in the hospital 
wards, and gained some adherents to the new faith among the leading 
physicians of the metropolis ; and finally, how, as the claims of vaccina- 
tion began to be recognized, at the close of the last century and commence- 
ment of the present, a most acrimonious discussion arose, which filled all 
the medical journals of that period. The opponents of vaccination resorted 
to every device to prevent the acceptance of Jenner's views. They at- 
tempted to prejudice the people against them by specious arguments, by 
ridicule, and even by pictures. One of the leading journals contained the 
caricature of a cow covered with sores, and devouring children, and it was 
urged that vaccination was a bestial operation, degrading man to the level 
of the brute. But the truth had gained a firm hold, and the practice of 
vaccination extended. 

The discovei'y of vaccinia, and of its protective power cannot be too 
highly appreciated. It has, probably, done more to relieve human suffer- 
ing than any other discoveiy of the last one hundred years, unless we 
except that of ansesthetics, and more to save human life than any other 
instrumentality of a purely physical kind. 

The fact was established in the time of Jenner that the virus of small- 
pox inoculated in the cow produced vaccinia, which, in its propagation 
back to man never returned to its original form, but always remained vac- 
cinia. Moreover, Jenner believed that the disease known in the horse as 
the grease was identical in nature with vaccinia in the cow. He failed, 
however, in his experiments to communicate vaccinia from the horse, but 
other experimenters have been more successful. In 1801, a Dr. Loy, of 
the county of York, England, met two eases of vaccinia in persons who 
had taken care of a horse affected with the grease, and, from the lymph 
which he obtained, was able to produce vaccinia in the cow. In 1805, 
Viborg, a Danish veterinary surgeon, after many failures, succeeded also 



204 VACCINIA. 

iu communicatiug vaccinia to the cow by means of the virus taken from a 
horse. 

From this time little light was thrown on this subject till within the last 
twenty years. Although Loy and A^iborg, and perhaps a few others, had 
recorded their success, other experimenters had failed to communicate vac- 
cinia from the horse. In the absence of additional cases, the profession 
began to question whether there might not have been some error in the 
observations of the gentlemen whose names I have mentioned, and the 
problem was still regarded as undetermined, whether a disease identical 
with vaccinia occurred in the horse, or a disease which might communi- 
cate vaccinia to the cow or to man. 

Observations confirmatory of those of Loy and Viborg were at length, 
however, made, w^hich must be regarded as conclusive. In 1856, iu the 
department of d'Eure-et-Loir, France, M. Pichot was consulted by a boy 
who had on the back of his hands vaccine pustules, which had apparently 
reached the eighth or ninth day. He had not taken care of nor been in 
contact with a cow, but had a few days before taken care of a horse affected 
with the grease. Vaccination was performed by means of the lymph taken 
from these pustules, and genuine vaccinia was produced. 

Again, in 1860, an epidemic prevailed among the horses in Riemes and 
Toulouse, France. A mare sickened with the disease, and there was swell- 
ing of the hough, with discharge of sanious matter. M. Delafosse vaccinated 
two cows Avith this matter, and communicated genuine vaccinia. This 
epidemic was believed by the veterinary surgeons to be an eruptive fever, 
differing iu its nature somewhat from the disease or diseases which have 
ordinarily been designated the grease. It has been conjectured that two 
or more distinct affections of the horse have the same appellation, one of 
which, it is now admitted, is identical Avith vaccinia of the cow, and may 
communicate it. And the reason why so many experimenters have failed 
to vaccinate the cow from the horse is that they have used the virus of the 
wrong disease, or have taken matter from horses which had been affected 
with the true disease, but from ulcers which had lost their specific character. 

Prior to the time of Jenner variolous inoculation was practiced in most 
civilized countries, as variola produced in this w^ay was found to be milder 
than when arising from infection. This practice is now obsolete; forbidden 
in some places by legislative enactments. It is superseded by vaccination. 
Vaccination, or the introduction of vaccine lymph into the system, is 
quickly and conveniently performed by scarifying with a lancet, and 
pressing into the incisions the lymph, or a little of the scab pulverized, 
and dissolved in a drop of cold water. It may also be performed by 
scraping off the epidermis W'ith the edge of the instrument till the blood 
begins to ooze ; and also, though with less certainty of success, by punctur- 
ing the skin with the point of the lancet, or by an instrument called the 
vaccinator. 



APPEARANCES SYMPTOMS. 205 

If the child has a vascular nsevus, this may be selected as the point of 
vaccination. Unless of large size, it can usually be cured by the inflamma- 
tion which vaccinia produces. Statistics collected by Simon, as well as 
Marson, show that of those who contract varioloid, the lai'ger the number 
of vaccine cicatrices the milder the disease, and the less the proportionate 
number of deaths. In Simon's statistics of those who stated that they had 
been vaccinated, but who presented no cicatrix, 21| per cent, died ; of those 
who had one cicatrix, 7^ per cent, died ; of those who had two, 4|- per 
cent, died ; of those who had three, If per cent, died ; while of those who 
had four or more cicatrices, only | per cent. died. These statistics would 
seem to indicate the propriety of vaccinating in several places. But, so 
far as appears, when two or more cicatrices were observed, the patients may 
have been vaccinated at different times, at intervals, perhaps of several 
years, and if so, the inference would not follow that more complete protec- 
tion is produced by vaccinating in several places than in one. Moreover, 
if vaccination is performed in the usual manner by several incisions on the 
arm, and the virus is fresh and active, usually two or more distinct vesicles 
arise, which unite in their development, and probably protect the system 
as much as if they were separated by a wider space. 

Appearances — Symptoms. — In genuine vaccination no effect is ob- 
served, except the slight inflammation due to the operation, till the close of 
the third day. Then the specific inflammation commences. This is indicated 
by a small red point, at first scarcely visible, indurated and slightly elevated, 
as determined by the touch, rather than by the eye. This increases, and 
on the fifth day the cuticde over the inflamed part begins to be raised by a 
transparent and thin liquid. The vesicle increases in diameter, and by the 
sixth day presents an umbilicated appearance, and is surrounded by a faint 
and narrow red zone. At the close of the eighth day the vesicle is fully 
developed. Its size varies considerably. It is usually from a sixth to a 
third of an inch in diameter, and oval or circular. If the vaccination has 
been performed by incisions, the size of the matured vesicle may be con- 
siderably larger, and its shape irregular, in consequence of the union of 
two or more vesicles. The eruption now presents a whitish or pearl-colored 
appearance, due to the whiteness of the cuticle, and the transparence of the 
liquid underneath. If the vaccination was performed by incisions, it is not 
unusual to observe over the centre of the vesicle, and adhering to it, a small 
yellowish scab, which has resulted from the scarification, and which contains 
none of the virus. 

The vaccine vesicle, like that of variola, consists of compartments, com- 
monly eight or ten, with complete partitions, so that there is no intercom- 
munication. On the ninth day the inflamed areola becomes more distinct, 
and its diameter rapidly increases. Its color is deep red, its temperature 
is considerably elevated, and it is accompanied by more or less induration 
of the subcutaneous tissue, and it is tender to the touch. On the tenth 



206 VACCINIA. 

day the pock has reached its full development. The areola then extends 
from one to two inches away from the vesicle, becoming fainter at its outer 
circumference, and gradually disappearing in the healthy skin. The shape 
of the outer circumference of the areola is irregular, projecting further at 
one point than another, though its general form is circular. 

On the tenth day, when the inflammation has reached its maximum, the 
heat, itching, and tenderness in and around the pock are such that the 
child is often feverish and restless. Occasionally the glands of the axilla 
become swollen and tender. In other cases, in which there is but a mode- 
rate amount of inflammation, the constitutional disturbance is slight. 

At the close of the tenth day, or on the eleventh, the inflammation 
begins to decline ; the areola becomes narrower and then disappears ; the 
induration and tenderness abate; and with this change the pustule desic- 
cates, its liquid is absorbed, and there results a brownish or a dark ma- 
hogany-colored scab, which is detached, ordinarily, between the fourteenth 
and twenty-first days. The cicatrix, at first reddish, like all recent cica- 
trices, gradually becomes paler, and remains whiter than the surrounding 
integument. It presents several minute depressions or pits, which indicate 
the genuineness of the vaccination. 

Anomalies, Complications, and Sequels. — The vesicle is often 
broken, accidentally, or by the nails of the child. If the top of the vesicle 
is destroyed, or most of the compartments are opened, the inflammation is 
commonly increased, considerable suppuration occurs, and there results a 
large, irregular, yellowish scab, consisting of the virus mixed with desic- 
cated pus. This scab is entirely unreliable, and unfit for the purpose of 
vaccination, though the protective power of the disease is not diminished 
by injury of the vesicles, even if it is totally destroyed. The cicatrix which 
results from extensive injury of the vesicle is apt to be large, and without 
the indented points which characterize the normal cicatrix. 

In rare cases, when the inflammation which surrounds the vesicle is in- 
tense and deepseated, suppuration occurs in the subjacent connective tissue, 
giving rise to an abscess. This abscess is commonly of small size, but it 
increases the fretfulness and constitutional disturbance which attend vac- 
cinia. This subcutaneous suppuration is believed to occur most frequently 
in those who have a scrofulous or vitiated state of system. Inflammation 
of the lymphatic glands of the axilla I have spoken of as not infrequent 
in vaccinia. This sometimes proceeds to suppuration, producing an un- 
pleasant, though not serious, complication. 

It sometimes happens that vesicles appear in other parts besides the 
points where the virus was inserted. These supernumerary vesicles com- 
monly occur where the cuticle has been removed by scalds or injuries. 

Trousseau relates the case of an infant whom he had vaccinated. On 
the eleventh day he was astonished to find twenty-seven vaccine pustules 
on the face, trunk, and limbs. This infant had, however, before the vac- 



ANOMALIES, COMPLICATIONS, AND SEQUELS. 207 

cination, a simple non-specific eruption over the whole body, and it was 
believed that it had produced these vaccinations by transferring the lymph, 
with its nails, to the various parts where the cuticle was denuded. 

It is not unusual, also, to observe minute papules appearing on parts of 
the surface simultaneously with or soon after the vesicle, and in a few days 
declining. These seem to be abortive vaccine eruptions. 

One of the most serious complications is erysipelas. This may occur 
directly from the operation, or from the inflammation caused by the vesi- 
cle, when the virus possesses no deleterious property ; and, again, it may 
result from some unknown element in the virus. It may occur imme- 
diately after the operation, when it commonly prevents the working of 
the virus, or during the vesicular or pustular stage ; or, again, after desic- 
cation and separation of the scab. I have observed it commencing at all 
these periods. 

Erysipelas, occurring as a complication of vaccinia, is invariably re- 
ferred by the friends to the virus employed, and the physician who has 
had the misfortune to vaccinate is often unjustly blamed. In many of 
these cases there was a strong predisposition to erysipelas at the time of 
the vaccination, and the operation or the inflammation which accompanied 
the normal development of the vesicle served simply as an exciting cause- 
Erysipelas would occur as soon from a non-specific sore ; indeed, we not 
unfrequently are called to cases of this disease in young children, which 
commenced from non-specific sores upon the genitals, or on one of the 
limbs. That the fault is not in the virus employed, is evident from the 
fact that other children, vaccinated with the same, have simple uncompli- 
cated vaccinia. 

Sometimes, on the other hand, the cause of erysipelas, whatever it may 
be, exists in the virus. For further facts in reference to this subject, the 
reader is referred to our remarks on erysipelas. 

The fact is established by many observations that syphilis is communi- 
cable by vaccination. The symptoms of it may not appear till vaccinia 
has terminated, or for a little time subsequently, but it then constitutes a 
very serious sequel. A physician of this city, well known in this com- 
munity as skilful in the diagnosis and treatment of skin diseases, and 
therefore not likely to be mistaken as regards the nature of the diseases, 
states that he communicated syphilis to two infants by vaccinating with 
the same scab. Both had the characteristic syphilitic eruption. Recently 
(January, 1(S68) an infant was brought to Prof. Alonzo Clark's clinique, 
in this city, having syphilitic rupia, which, in the opinion of the physi- 
cians present, was undoubtedly the result of vaccination. 

Trousseau relates the case of a young woman, eighteen years old, who 
was vaccinated with virus taken from an infant apparently in perfect 
healtli. The vaccination was unsuccessful; but twenty-three days subse- 
quently his attention was called to an eruption which had appeared in 



208 VACCINIA. 

two places on the woman's arm, corresponding with the points where the 
virus had been inserted. The eruption was that of ecthyma, which, by 
the next examination, which was five days subsequently, had been trans- 
formed into rupia. The axillary lymphatic glands were tumefied and 
indolent, and finally roseola appeared, which removed all doubts as to the 
syphilitic character of the disease. There was syphilitic infection, which 
first manifested itself in the points where vaccination had been performed 
{Article de la Vaccine). It is not ascertained in Professor Clark's case, 
nor is it stated in Trousseau's, whether the lymph or scab was employed 
for vaccination. There can be little doubt that the pure lymph never 
communicates anything but vaccinia, and if by vaccination any other 
disease is imparted, a little blood has mingled with the lymph, or the 
scab has been employed. 

The vesicle in genuine vaccinia is sometimes very small, not having a 
diameter of more than two lines. Occasionally the development of the 
vesicle is retarded. It does not appear till two or three days later than 
the usual time, or even a longer period. 

Vaccinia is modified by certain diseases. It is arrested by measles and 
scarlet fever, pursuing its course after the subsidence of the exanthem. 
On the other hand, it arrests the paroxysmal cough of pertussis, which 
returns when the pock begins to desiccate. Eczematous eruptions some- 
times occur after vaccinia, as they often do after the other eruptive fevers; 
or, if already present, they may be aggravated. 

Subsequent Vaccinations. 

A second vaccination, performed prior to the ninth day after the first 
vaccination, is successful. A genuine vaccine eruption results, which is 
smaller the more advanced the primary disease. This second erujjtion 
overtakes the first. On the ninth day the susceptibility to vaccinia is, in 
most cases, lost; so that vaccination performed on the tenth, or subsequent 
days, is unsuccessful. 

As a rule, an acute contagious disease occurs only once in the same 
individual. Vaccinia is an exception. In most cases, after a few years, 
it can be produced a second time ; and cases of a third or fourth success- 
ful vaccination, at intervals of a few years, are not uncommon. Now, 
subsequent cases of vaccinia differ from the first, which has been described 
above. The period of incubation is shorter, and the vesicular, pustular, 
and desiccative stages succeed each other more rapidly, so that the whole 
period of the disease is less. The variation from the appearance and 
course of the fii'st vesicle is proportionate to the degree of protection 
which the first vaccination still affords, both as regards small-pox and 
vaccinia. If several years have elapsed since the first vaccination, and 
the protective power which it afforded is nearly lost, the second vaccinia 



SUBSEQUENT VACCINATIONS. 209 

differs but little from the first. If, on the other hand, the first vaccina- 
tion still affords nearly complete protection, the result of the second is 
slight ; the eruption is insignificant, lacking the characteristic appearance 
of the vaccine vesicle, resembling a common sore, and disappearing within 
a week. It is not accompanied by the inflamed areola, or any appreciable 
constitutional disturbance. 

Vaccination often produces no result. This is sometimes due to the 
fact that the lymph or scab employed is useless. It has spoiled by keep- 
ing, or never has been good. In other cases it is due to a lack of suscep- 
tibility in the person. Some take vaccinia with difficulty, and only after 
several vaccinations ; just as children, though fully exposed, often fail to 
take measles or scarlet fever, on account of a condition of the system 
which prevents the reception of the virus, or antagonizes and controls its 
action. In some instances, after vaccination, an eruption is produced, 
which may or may not be genuine ; but it immediately becomes purulent, 
and is soon broken. A large, yellow, uneven scab results, having none of 
the appearance and containing little or none of the vaccine virus. This 
scab, as well as the liquid matter which preceded the formation of the 
scab, is utterly useless for the purpose of vaccination, and, if so employed, 
will probably cause a sore from its irritating effect, but not of a specific 
character. If, in place of the true vaccine vesicle, the eruption presents 
the appearance w'hich I have described, namely, that of a pustule, soon 
breaking and forming a large, irregular, yellowish scab, the vaccinia — if 
it is correct so to designate it — must be considered spurious. A sore has 
been produced by the animal matter which was employed in the vaccina- 
tion along with the virus, which has modified the action of the virus, and 
probably has rendered it useless as a means of protection ; or there may 
have been no virus inserted with this animal matter. The physician 
should in such cases insist on a second vaccination. 

Cases like the above are of frequent occurrence, and the parents of the 
child are often satisfied with the result. They see an eruption following 
the vaccination, accompanied by considerable inflammation, and leaving 
a cicatrix. Unless undeceived by the physician, they are apt to remain in 
the belief of the child's security, until, perhaps, it takes small-pox. Such 
cases, obviously, tend to diminish the confidence which the public should 
have in vaccination as a means of protection from small-pox, and on ac- 
count of their frequent occurrence it is important in all cases that the phy- 
sician should see the result of his vaccination. It has been proposed, as a 
means of determining the genuineness of the vaccinia, to .revaccinate when 
the eruption begins, and if the first is genuine, the second will ovei'take it. 
This is culled Brice's test; but it is not necessary, since the physician, 
familiar with the appearance of the true vesicle, can determine at once its 
genuineness by the sight. 

U 



210 VACCINIA. 



Protection from Vaccination— Revaccination. 

It was believed by the early advocates of vaccination that the general 
performance of this operation would soon eradicate sraall-pox from the 
community, so that it would be interesting only to the medical historian 
as a scourge of past ages. This result, however, is not achieved. As a 
rule, the greater the benefit of any measure designed to ameliorate the 
condition of mankind, the greater and more numerous are the obstacles 
which diminish its effectiveness. Science is full of examples of this. For- 
tunately these obstacles, as regards vaccination, are not such as to impair 
the confidence of physicians in its protective power, and it is not too much 
to expect that this simple operation will yet be the means of rendering 
small-pox a disease almost unknown, unless in its modified form. 

Vaccination should be performed in the first year of life. In the coun- 
try, whei'e there is little danger of exposure to small-pox, it may be deferred 
till the age of ten or twelve months. In the city, on the other hand, where 
there is constant intercourse of people, and where contagious diseases are 
often contracted in ignorance of the time and place of exposure, au 
earlier vaccination is advisable. Some physicians recommend performance 
of the operation as early as the age of four to six weeks. The objection to 
this is, that if erysipelas occur, so young an infant is ajDt to perish from it, 
whereas an infant three or four months old ordinarily recovers. For this 
reason I believe that the most suitable age is about four months for the city 
infant, in ordinary times ; but if small-pox is epidemic, vaccination should 
be performed at an earlier age. I have vaccinated even the new-born in- 
fant when small-pox had broken out in adjoining apartments. 

Vaccinia usually extinguishes, for a time, the susceptibilty to small-pox. 
According to M. Gintrac, varioloid does not occur within two years in those 
who have been vaccinated. It may, however, in exceptional instances, 
occur in a mild form within a few months after vaccination. The protec- 
tion afforded by vaccination gradually diminishes by time, but it does not, 
probably, as a rule, cease entirely. Varioloid, however, occurring thirty 
or forty years after a successful vaccination, is apt to be severe, and it may 
even be fatal, showing that it has been but slightly modified. In other 
cases, even after so long an interval, the symptoms present a degree of 
mildness which indicates that the protective power of the vaccination is 
not entirely lost. 

If a second vaccination is practiced soon after the scab from the first 
vaccination has fallen, it will usually produce no result, but in other cases 
it gives rise to a little redness, swelling, and induration, which show that 
vaccinia has been reproduced, though in a very mild and insignificant 
form. It is probable that in these cases varioloid might also occur by 
exposure, though with a mildness corresponding with that of the vaccinia. 
The longer the period after the first vaccination, the greater the number of 



SELECTION OF VIRUS. 211 

those in whom a secoud vaccination is effective, and, as has already been 
intimated, the greater also the liability to the variolous disease if a second 
vaccination is not performed. Therefore a second vaccination should be 
performed about the sixth or eighth year, and again between the fifteenth 
and twentieth year. And if small-pox is epidemic, it is proper to vaccinate 
all who have not been vaccinated within three or four years. 

Selection of Virus. 

The lymph is preferable to the scab for vaccination, provided that it 
can be obtained fresh. The scab is more easily preserved, and, therefore, 
if the lymph and scab are old, the latter is to be preferred. The lymph 
should, if the vesicle is sufficiently developed, be taken on the fifth day. 
It may also be taken on the sixth, seventh, or even eighth day, provided 
that the areola has not formed. The lymph of the fifth day acts with 
greater energy, though that of the sixth or seventh day is not much infe- 
rior. Lymph obtained after the formation of the areola is less efficient, 
though it may communicate the genuine disease. 

There is no mode of vaccination so reliable as the use of lymph, taken 
directly from the arm and immediately inserted — the arm to arm vacci- 
nation. Lymph can be preserved for a few days on a flattened surface of 
whalebone, or the segment of a quill, and if employed within a week, it 
will usually communicate vaccinia. Lymph may be preserved a longer 
period between two surfaces of glass, but the best way of preserving it is 
in capillary glass tubes. The end of the tube is placed within the vesicle, 
and the lymph ascends by capillary attraction. When a sufficient quan- 
tity is received, the ends are sealed, by holding them for a moment in a 
flame. Care is requisite in doing this, so as not to heat the lymph, as it 
is spoiled by a temperature much above the body. When the lymph is 
used, the ends of the tube are broken, and by blowing gently through it, 
a sufficient quantity is received on the point of a lancet. 

If the scab is genuine, it presents a dark-brown or mahogany color, and 
has a circular, oval, or at least a rounded form ; it is firm, or compact, and 
has a lustre. Soft, yellowish, and irregular scabs are not genuine, and 
those of a dull apfjearance, or without lustre, have usually spoiled in the 
keeping. The scab is best preserved in soft beeswax, which excludes the 
air, and it should be kept in a cool place. It is the belief of many that 
the vaccine virus gradually becomes weaker by passing successively through 
the human system (Condie, American Journal of the Medical Sciences, 
April, 1865), and that therefore different specimens of virus work with 
different energy, according to the degree of removal from the cow. To 
what extent this view is correct is not fully ascertained, but, certainly, if 
the virus employed continues to produce a small vesicle, and attended 
only by little inflammation, there is reason to believe that the protection 



212 VAEICELLA. 

which it imparts is less thcan that from virus which works with greater 
energy, and it should be exchanged for such. In New York we are able 
to obtain at any time lymph directly from the heifer. It has never passed 
through human blood, for the original lymph came from cattle in one of 
the provinces of France, where vaccinia was prevailing epidemically. 
The popular objection to vaccination is obviated by the use of this lymph, 
but it works with great energy, producing a large pock, and a sore which 
is often a month in healing. I have found it very reliable, and prefer to 
use it in ordinary cases, notwithstanding the severe symptoms which it 
produces. 



CHAPTER VI. 

VARICELLA. 

Varicella, chicken-pox or swine-pox, is the shortest and mildest of the 
eruptive fevers. It is highly contagious, so that few children escape who 
are exposed to it. Its period of incubation is from fifteen to seventeen 
days. It is not inoculable, or at least those who have attempted to inoc- 
ulate with the lymph of varicella have failed. I endeavored to commu- 
nicate the disease in this way some years ago, but without result. It 
attacks the same individual but once, and it occurs as an epidemic. It 
has been thought by some, to prevail most immediately before, during, or 
after epidemics of small-pox, and it has been conjectured that it is a 
modified form of variola, and hence its name, which signifies little variola. 
This idea is, however, entertained by few, and it is opposed by the follow- 
ing facts. Varicella may occur after variola, or variola after varicella, 
without any modification, and the two diseases are very dissimilar as 
regards gravity of symptoms and duration. The variolous disease, whether 
small-pox or varioloid, often occurs in the adult; varicella, on the other 
hand, is a disease of infancy and childhood. Professor Flint states that 
he has observed it in the adult, but its occurrence at this period of life is 
rare. Moreover varicella and variola have been known to occur simulta- 
neously in the same individual. Such a case was reported by M. Delpech, 
in a memoir published in 1845. 

Symptoms. — Varicella usually commences with such symptoms as usher 
in ordinary mild febrile attacks, namely, headache, languor, chilliness, 
and sometimes aching in the back and limbs. Fever supervenes, which 
is usually moderate, the pulse rising perhaps to 100 or 112, and the ther- 
mometer showing an increase of temperature, but less than occurs in the 



DIAGNOSIS. 213 

other eruptive fevers. These symptoms which precede the eruption, are 
sometimes absent, or are so mild as to escape notice. The fever usually 
ceases on the second day, but it may return on the following night. The 
appetite is rarely lost, and most children continue, more or less, at their 
amusements. 

The eruption commences in about twenty-four hours, appearing as small 
red points, first over the trunk, and soon afterwards over the face and 
limbs. These points, which are at first minute papules, become vesicular 
in the course of a few hours. The occurrence of the vesicular stage is 
nearly simultaneous on all parts of the surface. The vesicles lack the hard, 
indurated base of the variolous eruption, though they are sometimes sur- 
rounded by a faint zone of redness. They differ also from the variolous 
eruption in the absence of urabilication, and in irregularity of shape. 
Some are small and acuminate, some hemispherical, and of medium size, 
and others oval or elongated, and of large size. The inflammation is quite 
superficial, not involving the subcutaneous tissue, and scarcely affecting 
the deepest layer of the skin. 

The vesicles vary in size from the diameter of half a line to that of even 
three lines. They occasionally give rise to slight itching. On the second 
day of the eruption, or third of the disease, the vesicles are still fully de- 
veloped, their liquid contents being nearly transparent. At the close of 
this day the liquid begins to be somewhat cloudy, and its absorption com- 
mences. On the fourth day of the disease desiccation progresses rapidly, 
and by the fifth the liquid has for the most part disappeared, and there 
results a scab, small and thin, of a yellowish-brown color. The scabs are 
soon detached, the redness which indicated their seat disappears, the epi- 
derm which had been raised and removed by the eruption is reproduced in 
its normal state, and in a few days all evidence of varicella is effaced. A 
cicatrix occasionally results, but it is due not to the simple varicellar erup- 
tion, but to a sore produced from the eruption by the scratching of the 
child. 

The number of vesicles varies considerably in different cases. They are 
never, so far as I have observed, couffuent; but they are sometimes so 
abundant in young children that, if the disease were variola, it would be 
called severe discrete. 

Diagnosis. — Obviously the only diseases with which varicella is liable 
to be confounded are such as present vesicles at some stage of their course. 
From the local vesicular eruj^tions this disease is diagnosticated by the 
fact that the vesicles appear on all parts of the surface. It is sometimes 
mistaken for variola or varioloid, or vice versa — a mistake very damaging 
to the reputation of the physician. The points of differential diagnosis are 
the symptoms of invasion — severe, and lasting three or four days in the 
one; mild, and continuing only one day in the other — an eruption passing 



214 VARICELLA. 

slowly through its stages from the papulie to the pustulse, umbilicated, with 
circular, raised, and iuflamed base, appearing first on the face and neck, 
and not till a day later on the legs, in the one disease ; while in the other 
the evolution, shape, and course of the eruption, as described above, are 
materially different. By proper attention to these distinctive features it is 
rarely difficult to diagnosticate the two diseases. 

The PROGNOSIS in varicella is always favorable. It does not, of itself, 
endanger life, nor seriously incommode the patient ; nor does it give rise 
to complications nor sequels. The treatment, therefore, is the simplest 
possible. Mild diet, and a laxative, may be prescribed during the febrile 
period ; but nothing further is required. 



SECTION III. 

NON-ERUPTIVE CONTAGIOUS DISEASES. 

CHAPTER L 

DIPHTHERIA. 

Diphtheria is a disease of antiquity. Aretseus, at the close of the 
first century of the Christian era, described the Malum ^gyptiacum as a 
malady which occurred chiefly among children, and was characterized by 
a white concretion spreading over the tonsils, a fetid breath, and, in some 
patients, by a I'eturn of food through the nostrils, and by great dyspnoea, 
ending in suflEbcation (Oertel). Since the commencement of the sixteenth 
century numerous epidemics of it have been observed in Europe and North 
America, and at the present time it is one of the most common and fatal 
epidemic maladies on both continents. 

Age. — Diphtheria is pre-eminently a malady of childhood, a large 
majority of the cases occurring between the ages of two and ten years. 
Under the age of one year, the younger the child the less the liability to 
it, and it rarely occurs prior to the fourth month. The age of the youngest 
patient in my practice, so far as I recollect, whose disease was undoubtedly 
diphtheria, was three months and a few days ; but, in one instance, I ob- 
served upon the fauces of an infant of six Aveeks, whose brother had just 
died of diphtheria, a few white specks, like grains of salt, over each tonsil, 
which disappeared in three or four da)'s (without the occurrence of any 
marked symptoms) by the application of chlorate of potassa in solution. 
Cases are infrequent after the middle period of life, and old age seems to 
possess nearly an immunity from diphtheria. 

Incubation. — Diphtheria has an incubative period, which varies from 
two or three to eight or nine days. The history of the following cases 
which occurred in my practice are common examples, showing the manner 
in which diphtheria spreads in families, and the usual intervals between 
cases. Mrs. E. assisted in nursing a fatal case of diphtheria living in 
another house, from November 11th to 13th, 1874, after which she re- 
turned home. On the evening of the 15th she complained of soi'e throat, 
and on the following day the diphtheritic pseudo-membrane was observed 



21G DIPHTHERIA. 

over her tonsils. On the 19th she had entirely recovered by local treat- 
ment. On the 20th, her sister, residing with her, was similarly affected, 
and in three or four days was also cured by the same treatment. The only 
other case in the family, a boy, sickened with diphtheria on December 2d. 

Nature — Causes. — The frequent occurrence of epidemics of diphtheria 
during the last twenty-five years, and the great mortality which has at- 
tended them, have awakened an interest in this malady which has led to 
a careful study of its causes and nature. Till recently these inquiries were 
entirely clinical, but, during the last few years, a new line of investigation 
has been followed, namely, that of experimenting on animals, the results 
being observed by the microscope ; and while it has led to the confirma- 
tion of facts already ascertained, important discoveries have been made, 
and more important ones are probably in waiting. Those who have taken 
the lead in this new field of investigation are Oertel, Biihl, and Hueter, 
of Germany. These microscopists, and several other experimenters of 
equal reputation, confirm their views, believe that they have discovered 
the cause of diphtheria, standing, as Oertel says, " on the very borders 
of the visible," with a high power of the microscope. 

This discovery is so important, not only in itself, but from the promise 
which it gives of the results of future research, and from the stimulus 
which it imparts to such inquiries, that a brief statement of the facts in 
reference to it cannot fail to be interesting at the present time, when diph- 
theria is so prevalent and fatal in this city and country. ,The minute 
objects which the observers alluded to, have discovered in patients aflfected 
with diphtheria, and which, they suppose, cause the disease, are endued 
with life and motion. They belong to the class of microscopic vegetable 
parasites, which have been designated bacteria. The bacteria have been 
divided by Cohn into four genera, with species ; but only two of these, it 
is thought, sustain a causal relation to diphtheria, namely, the sphero- 
bacterium or spherical bacterium, or, as Oertel designates it, the micro- 
coccus; and secondly, though in less degree, because less numerous, though 
coexisting with the other form, and penetrating the tissues with it, the 
micro-bacterium, or rod-like bacterium. 

The microscope, in the hands of various observers, has revealed the fol- 
lowing important facts relative to diphtheria : In every tissue, which is the 
seat of diphtheritic inflammation, and in every diphtheritic pseudo-mem- 
brane, the spherical bacteria occur in immense numbers, accompanied by 
a smaller number of the other kind. In severe cases, in which the system 
is infected, they occur also in the blood. Ordinarily, as the symptoms of 
diphtheria become more grave, a proportionate increase in the number of 
spherical bacteria can be demonstrated by the microscope. They are found 
in the discharge from the edges of the wound produced by tracheotomy, 
performed in the treatment of diphtheritic laryngitis, and upon these 
edges they multiply rapidly, just before a pseudo-membrane forms. If, 



NATURE — CAUSES. 217 

upon any surface, which is the seat of ordinary catarrhal inflammation, 
other vegetable organisms, as the leptothrix buccalis, or oidium albicans, 
are present — if diphtheritic inflammation supervene, these organisms 
diminish and disappear, as if deprived of the required nutriment, and are 
succeeded by the sphero- and micro-bacteria, which increase in numbers 
as the specific inflammation extends. On the other hand, when the diph- 
theritic inflammation abates, these bacteria disappear, and other vegetable 
forms may succeed. In the very commencement of diphtheria, the grayish, 
white sjDots which appear upon the inflamed surface, consist entirely of 
these bacteria, with epithelial cells and mucus, while fibrin and pus appear 
at a later period, as a result of inflammatory reaction. 

These facts having been ascertained, various experiments were made by 
Oertel, Hueter, Von Trendelenburg, Nasseloff", Eberth, and others, in 
order to determine more fully the exact relation of the sphero-bacteria 
and micro-bacteria to diphtheria. These organisms were not found in the 
croupous membrane, produced by the application of a powerful chemical 
agent, as ammonia, nor upon the inflamed surface underneath the mem- 
brane, " although the fibrinous exudation afforded a soil which varied little 
or not at all in its histological and chemical composition from that induced 
by diphtheria." (Oertel.) The mucous membrane of the air-passages, 
the cornea and muscles in animals, were inoculated with diphtheritic matter, 
and these two kinds of bacteria were found to increase rapidly, penetrating 
the tissues in a short time, and infecting the system. Oertel says : " I 
have noticed in numerous inoculations that if various bacteria, besides the 
micrococcus, as, for instance, bacillus, spirillum, and bacterium lineola, 
were present in the matter to be inoculated, only micrococci (sphero-bac- 
teria) and the bacterium termo (in its most minute forms accompanying 
them) showed evidence of prolific growth, while all the other forms disap- 
peared altogether." Nasseloflf and Eberth inoculated the cornea with 
diphtheritic matter, and found that the sphero-bacteria and micro-bacteria 
penetrated its layers, forcing them apart, and causing within a few days 
intense keratitis and the death of the animal by infection of its blood. 
"In the same way," says Oertel, "according to my experiments, the bac- 
teria spread over the mucous membrane of the trachea, beset the cellular 
elements, crowd especially into the young exudation cells, or are taken up 
by them, and gradually cause their dissolution ; they fill the blood- and 
lymph vessels, and bring about, in a mechanical way, a damming up of 
the fluids, and, as a consequence, serous exudation. As they close up the 
capillary vessels, they occasion stagnation in the blood circulation, which 
induces disturbance of nutrition in the walls of the capillaries, and even 
rupture of the same. Muscular fibres, also, which are covered and filled 
with colonies of micrococci, degenerate and slough ; in like manner, in 
severe cases, immense numbers of bacteria appear heaped up in the uriuif- 
erous tubules and Malpighian corpuscles of the kidneys, and occasion 



218 DIPHTHERIA. 

there parenchymatous inflammation, capillary embolism of the glomeruli 
of the kidney, with ruptured vessels and formation of epithelial casts in 
the tubes. In the lymph and blood streams (compare also Hueter), where, 
in long-continued sickness of the animal experimented on, these bacteria 
also accumulate in masses. They induce as excitors of decomposition and 
disorganization of organic nitrogenous bodies, septicsemia, through the 
vegetative process they undergo, and through their relation to oxygen." 

Finally, Erfurth repeatedly inoculated the cornea with a negative result, 
using for the purpose diphtheritic material from which the bacteria had 
been so far as possible separated. 

The importance of such experiments cannot be too highly estimated. In 
the opinion of those who have performed them, the conclusion is inevitable 
that diphtheria is produced by bacteria, which, coming in contact with the 
mucous membrane, or the cuticle deprived of its epidermic covering, ad- 
here to it ; and these multiplying rapidly, burrow through the tissues, and 
entering the vessels, infect the whole system. The reason assigned why 
diphtheritic inflammation in most cases appears primarily and chiefly upon 
the faucial and nasal surfaces, is that the air, which contains the germs of 
the bacteria, constantly passes over these surfaces, and, as regards the fauces, 
the ingesta also, which may contain them. The important practical in- 
ference from this theory is, that diphtheria is entirely local in its com- 
mencement, and is amenable to local measures. 

These experiments, apparently so conclusive, and the brilliant results 
claimed for them, probably produce at first in most persons engaged in 
microscopial or pathological studies, a degree of enthusiasm in the belief 
that a new era is dawning in our knowledge of the contagious and mias- 
matic diseases. And since the German microscopists and pathologists are 
close and accurate observers, we accord to their researches and opinions a 
degree of credence which we are reluctant to yield to our own scientists 
who are engaged in similar studies. 

But the causes and nature of a disease cannot, in general, be fully 
elucidated by experiments alone, such as have been detailed. They should 
be aided or supplemented by clinical observations, and of these, as regards 
diphtheria, we have had an abundance in New York during the past fifteen 
years. Clinical observations may modify or correct the theories derived 
from the results of experiments. 

Two distinct propositions are evidently included in the bacterian theory, 
to wit : that bacteria cause diphtheria, and secondly, that this disease is at 
first local, and that afterwards it becomes constitutional or general by the 
entrance of the specific principle into the blood. Whether diphtheria is 
primarily local or primarily constitutional, or is in some at first local and 
in others at first constitutional, is of course a distinct proposition from that 
regarding the relation of bacteria to the malady; and whatever the truth 
may be in reference to the one, does not affect the other. 



NATURE — CAUSES. 219 

Is diphtheria, whatever its cause, primarily local ? A fact in support 
of the opinion that it is strictly local in its commencement, I think that 
all physicians, who have seen much of it, have frequently observed, 
namely, that it may commence with high fever and other grave symptoms, 
and a genuine diphtheritic pseudo-membrane begin to form upon the fauces; 
and yet, by prompt and judicious treatment, these symptoms abate, the 
inflammatory redness and exudation disappear, and the health be fully 
restored within three or four days. What satisfactory explanation can 
there be of such cases in which restoration to health is so rapid, except 
one based on the supposition that the blood v/as not yet contaminated ; 
the disease being eradicated when it was still local ? 

If, on the other hand, diphtheria has continued four or five days when 
the physician is called, and such instances are common among the poor of 
New York City, however thorough and judicigus the treatment, the malady 
is seldom cut short as in the other cases. There is now a manifest cachexia 
and an obstinacy in the symptoms, which contrast strongly with the cases 
just alluded to. Why this difference, except that in these last cases diph- 
theria is no longer local, but has involved the blood and the entire system? 
Again, the fact that in almost all instances the primary manifestation of 
diphtheria is at one point only, as upon the fauces, and that afterwards 
various diphtheritic inflammations may occur in different parts of the 
system, favor the idea that the contagious principle at first acts only 
locally. Again, diphtheria has been repeatedly known to commence upon 
the fresh sore of a surgical operation, the patient at the time being per- 
fectly well, except as regards the surgical ailment. This admits of no 
plausible explanation other than that the specific principle has alighted 
upon the sore, and has there produced the specific inflammation by its 
strictly local action. 

Nevertheless, any theory which regards diphtheria as always a local 
malady in its commencement, will not, I think, be accepted by physicians 
who see most of the disease. Although it is probably true as regards many 
or most cases, there are others in which, from the severity of the initial 
symptoms and the little amount of local disease, there is every reason to 
suppose that the blood is already contaminated. Probably in these cases 
the contagious principle, whether bacteria or something else, has entered 
the blood through the lungs. Thus, cases are not infrequent in which there 
is on the first day a temperature of 102° or 103°, with pulse from 120 to 
160 per minute, and yet there is no pseudo-membrane, and but a very mode- 
rate amount of faucial inflammation. 

Again, does not the fact of an incubative period of several days, in cer- 
tain cases of diphtheria, indicate that in these cases the blood is infected 
prior to the occurrence of the local phenomena ? Although the diphtheritic 
virus in most instances begins to act within two to five days after exposure, 
there is, as we have seen in other instances, an incubation of a week or ten 



220 DIPHTHERIA. 

days. We cannot suppose that all this time the virus has been clinging to 
the throat in a quiescent state. It is more probable that it has entered the 
blood directly through the lungs, and that, in this fluid, it has increased in 
quantity or intensity, till it was sufficiently energetic to produce the in- 
flammation upon the surface. Clinical experience, therefore, I think, jus- 
tifies the belief that diphtheria is, in certain cases, a constitutional malady 
in its commencement, while in other, probably in most cases, it is primarily 
local, and subsequently constitutional. But the theory that bacteria cause 
diphtheria is not, of course, invalidated by the admission that the blood or 
system is sometimes infected before there is any local manifestation of the 
disease. Its truth or falsity must be determined by other considerations. 

The view that diphtheria is caused by fungi receives support from the 
fact that it prevails most in places which are favorable to the development 
of low forms of animal and vegetable life, viz., in filthy and crowded apart- 
ments, along streets and alleys, and on low grounds, where vegetable and 
animal refuse collects. The contagious principle of diphtheria, therefore, 
if not the sphere- and micro-bacteria, has, to say the least, similar condi- 
tions for its development. It is, no doubt, some substance or entity which, 
if not already, may yet be discovered, either by the microscope or chemi- 
cal analysis; and the phenomena of the disease indicate that if it be not 
the bacteria, it is, in all probability, something which is, in certain respects, 
similar to them. 

But while certain facts lend support to the bacterian theory, certain 
other facts show, in my opinion, that there must be some other cause of 
diphtheria which is distinct from the bacteria. These facts the advocates 
of this theory have too much ignored. They are the following : In the 
intervals of epidemics, and in localities where diphtheria has not occurred, 
or has occurred rarely, the microscope discloses the existence of bacteria, 
which seem to be identical with those found in diphtheric inflammations, 
and in sufficient numbers to justify the belief that they frequently pass 
over the fauces in the inspired air. Again, bacteria, which seem to be 
identical with those of diphtheria, are frequently found upon the gums, be- 
tween the teeth in a state of health, where they produce no perceptible 
irritation. How remarkable, if the bacterian theory is true, that fungi, 
which, under ordinary circumstances, are innocuous, should exhibit the 
fearful energy and destructive power which we observe in diphtheria ! It 
has been, however, suggested to me by a physician familiar with micro- 
scopical and pathological studies, that the diphtheritic bacteria may yet be 
ascertained to be different from the ordinary micrococcus, since the bac- 
teria are very numerous, and it is very difficult to distinguish or identify 
organisms, which are "just on the borders of the visible." A fact which, 
till it is satisfactorily explained, must produce skepticism, it seems to me, 
in regard to the bacterian theory is, that the bacteria do not irritate the 
lungs. Certainly, if during inspiration, certain of them, carried along in 



NATURE — CAUSES. 221 

the current of air, are arrested upon the fauces, where they produce the 
specific inflammation, a larger number must enter the lungs, where, we 
would suppose, from the delicate structure of these organs, and their prone- 
ness to inflammation, they would produce a general and severe pneumonia. 
So far from this being the case, pneumonia is a rare complication of diph- 
theria. 

Since the publication of the bacterian theory, I have made microscopic 
examinations of diphtheritic pseudo-membranes, in order to observe the 
form and movements of the micrococci, and the effect upon them of the 
medicinal substances which I have been in the habit of applying to the 
throat in diphtheria. With a magnifying power of 500 diameters, these 
parasites are seen as dancing or oscillating points, or rather as minute cells, 
shining or opaque, according to their distance from the eye. No one can, 
I think, observe their constant motion without admitting that they may, 
when in colonies, be irritants of the tissue with which they are in contact 
iu the system, thus producing or intensifying the inflammation; and with- 
out also believing, since they are so much smaller than the blood-cor- 
puscles, that multitudes of them must enter the circulation, since, in the 
deepest portion of the pseudo-membrane, they are in immediate relation 
with the capillaries and lymphatic vessels. It is not improbable, in view 
of these facts, that the spansemia of diphtheria is partly attributable to 
these organisms in the lymph and blood, for they could hardly exist in 
these liquids in any number without interfering seriously with the nutri- 
tive process. 

It is evident that the truth regarding the relation of bacteria to diph- 
theria lies in one of two hypotheses, — either that these parasites are the 
specific virus, and therefore cause the disease ; or that the cause is some- 
thing more subtle not yet discovered, which so alters the tissues and the 
blood that they become a nidus in which the bacteria are early and quickly 
developed, so that from being few and innocuous in the system, they occur 
in myriads. 

My own belief is more and more confirmed that the latter is the true 
theory, and thatOertel and his associates have mistaken a consequence for 
a cause. I have lately, with my friend. Dr. Heitzmann, recently of Vienna, 
a most excellent microscopist, examined the secretions and exudations upon 
the fauces in various cases of pharyngitis, both diphtheritic and non-diph- 
theritic ; and we have always found the micrococcus in abundance in the 
inflammatory product, whether diphtheritic or non-diphtheritic, a secretion 
or exudation, if it had remained for some time upon the surface of the 
fauces. In one case of simple pharyngitis no micrococcus could be dis- 
covered on the first day in the secretion which lay in the depressions over 
the tonsils, while on the second day numerous micrococci had appeared. 
The micrococcus in the inflammatory product upon the fauces certainly 
does not indicate disease of a specific nature. Does not also the general 



222 DIPHTHERIA. 

prevalence of inflammatory throat affections, some of which are very mild, 
during an epidemic of diphtheria, indicate an obscure meteoi'ological cause 
of the disease quite distinct from the bacteria? Moreover, does not that 
common sequel of diphtheria, namely, paralysis, indicate that there is 
something peculiar in the diphtheritic virus, that it is distinct in nature 
and action, from the bacteria, and from septic poison, for those who re- 
cover from septicaemia, as it occurs in surgical and other cases, and in 
which disease bacteria are abundantly developed in the blood, have no 
special liability to paralysis. Without pursuing these thoughts farther, we 
will recapitulate some of the more important facts, relating to the causes 
and nature of diphtheria, which have either been fully established, or ren- 
dered highly probable. 

1st. Diphtheria is a local malady in its commencement in most instances, 
occurring from lodgment of the diphtheritic poison at some point upon 
the mucous membrane, or upon the skin denuded of its epidermis, or upon 
an open sore. When thus localized it may, by proper local treatment ap- 
plied early, be cured, and the system remain unaffected. 

2d. When diphtheria has a local commencement, infection of the system 
occurs by absorption of some of the morbid product, through the absorb- 
ents or capillaries, or both, which connect with the seat of the disease 
upon the surface. What this substance is which thus infects the system 
and produces the constitutional symptoms of diphtheria is unknown. 
Much confusion and difference of opinion exists in regard to it. The fol- 
lowing are theories respecting it : that it is a virus which is peculiar (diph- 
theritic) and quite distinct from the bacteria ; that it is bacteria ; that it is 
septic poison, absorbed from the inflamed surface, and not different from 
the poison in ordinary septicsemia. And then there are the different views 
in regard to the nature of the septic poison, that it is the bacteria, a secre- 
tion of the bacteria, etc. What it is which produces the external inflam- 
mations of diphtheria, and what it is which infects the blood, and the rela- 
tions of this substance to bacteria on the one hand, and to septic poison on 
the other, must be determined by futui-e investigations. 

3d. Acute cervical adenitis and cellulitis, producing tumefaction along 
the neck, are of grave import in diphtheria, since they show that the poison 
has entered the lymphatics, and infection of the system is inevitable. They 
sustain the same relation to diphtheritic pharyngitis as the bubo sustains to 
a chancre, or as adenitis in the axilla to a poisoned sore upon the hand or 
arm. 

4th. There can be little doubt that the diphtheritic poison sometimes 
enters the system through the lungs in inspiration. My friend Dr. Heitz- 
maun informs me that he made the post-mortem examination of a child 
who died within the first day of diphtheria, which was prevailing in the 
family. The examination was made soon after death, and portions of the 
lungs were placed in a solution of bichromate of potassa to prevent decom- 



NATURE CAUSES. 223 

position. He observed bacteria under the microscope in the minutest 
bronchial tubes, and no pseudo-membrane could be discovered on any of 
the mucous surfaces. This was certainly a very important case if there 
were no error in observation. And since bacteria occur so quickly on sur- 
faces upon which the diphtheritic virus is acting, and as the other mucous 
surfaces, appeared noi-mal, may we not infer that in this case the virus 
had been received directly into the tubes in the inspired air? 

We therefore recognize two modes of systemic infection, namely, by in- 
oculation upon one of the tegumentary surfaces, and through the lungs; 
modes in which it is well known that certain other acute infectious dis- 
eases are, or may be, communicated, as for example, scarlet fever and 
variola. 

5th. In whatever Avay the virus enters the system, it is specially at- 
tracted to the fauces, and therefore pharyngitis is commonly its earliest 
and most severe local manifestation. 

6th. It is customary in medical treatises to classify diphtheria among 
the acute infectious diseases, along with scarlet fever and measles. Unlike 
those diseases, however, it often occurs in a secondary as well as a primary 
form. It is an interesting and important fact that diphtheria instead of 
being incompatible with other distinct morbid processes, sometimes en- 
grafts itself upon them, especially upon the other acute infectious diseases. 
"Diphtheria," says a foreign writer, " develops very rapidly under the in- 
fluence of poisonous miasms — during the prevalence of hospital gangrene, 
putrid fevers, and bad epidemics of typhus fever, and under these circum- 
stances it not infrequently reaches its highest point of virulence and its 
widest extent." In this city most cases of secondary diphtheria occur as 
complications of scarlet fever and measles. The mortality, indeed, of these 
eruptive fevers is greatly increased by the frequent supervention of diph- 
theritic inflammation upon the fauces or in the larynx, in cases which would 
otherwise do well. An interesting fact I have several times observed, 
namely, that diphtheria originating upon the inflamed surface in scarlet 
fever or measles, may become dissociated, and spread as an independent 
malady. Thus in one family three children affected with severe anginose 
scarlet fever, took also diphtheritic pharyngitis before the efflorescence on 
the skin had disappeared. A few days subsequently diphtheritic pharyn- 
gitis appeared in the father without scarlet fever. 

7th. Certain recent writers (George Johnson and others) state that 
"membranous croup and laryngeal diphtheria, as we now see them, are 
one and the same disease." (Ijondon Lancet, Jan. 16th, 1875.) There can, 
however, be no doubt that there is a membranous croup which is quite 
distinct from diphtheria. I saw many such cases in New York prior to 
1858, when there had been no diphtheria in the city for many years. In 
no one of these cases was there the history or any evidence of contagious- 
ness; but, on the other hand, as they occurred singly, the proof was strong 



224 DIPHTHERIA. 

of their non-contagiousness. Nevertheless, at the present time, when the 
diphtheritic poison is so abundant in the atmosphere, we certainly have 
few cases of membranous croup which are not diphtheritic, or do not be- 
come such. It is not improbable that the exudate of true croup affords a 
nidus in which the diphtheritic virus lodges and multiplies so as to trans- 
form a simple croupous into a diphtheritic inflammation, just as we have 
seen scarlatinous pharyngitis becomes diphtheritic. In no other way can 
I explain the comparative infrequency of croup as we observed it in former 
times. 

Diphtheria has scarcely been absent from New York for a single season 
during the last ten or fifteen years — the primary form predominating dur- 
ing diphtheritic epidemics, and the secondary form in the intervals, and 
during epidemics of scarlet fever and measles. Diphtheria may, indeed, 
be properly designated an endemic in this city. 

Diphtheritic inflammation, as is well known, attacks by preference such 
exposed surfaces as are deprived of their epithelial or epidermic covering, 
and especially such surfaces when they are already irritated or inflamed. 
It attacks most quickly and violently such inflamed surfaces when there is 
a low vitality of the tissues, whether produced by the primary disease or 
habitual. In this fact I find an explanation of the frequent complication 
of scarlatina and measles by diphtheria, as already alluded to ; for in these 
eruptive diseases an inflammation is already established upon the fauces 
and in the air-passages, affording a nidus in which the diphtherite virus, 
whatever it is, lodges and is developed. 

The anti-hygienic conditions which favor the occurrence and spread of 
diphtheria are too well known to require more than a passing notice. 
When diphtheria reappeared in New York in 1858 after an absence of 
more than fifty years, some of the first and most severe cases seen by my- 
self occurred in the uj^per part of the city, along the old water-courses, 
where in consequence of street grading, water was stagnant and impreg- 
nated with decaying animal and vegetable matter. Though observing 
and treating diphtheria, both in its epidemic and sporadic form, during 
the last fifteen years, I have not observed an instance in which it seemed 
to be communicated from house to house by the clothing, as we frequently 
observe in cases of scarlet fever, and sometimes of measles. When it 
spreads from house to house, or even from room to room, in the same 
house, I think that it is almost always by the visits of persons having 
diphtheritic inflammation. The area of contagiousness of diphtheria is 
therefore limited to the room, in which the patient resides, or to his im- 
mediate vicinity. 

But it is well known that the sputum of a diphtheritic patient and bits 
of diphtheritic pseudo-membrane may communicate diphtheria. The ex- 
periments indeed show this, as do many observations published in the rec- 
ords of diphthei-ia. Therefore, caution is required that children be not 



ANATOMICAL CHARACTERS. 225 

exposed needlessly by the handkerchiefs or towels employed by a patient, 
nor to his breath, especially during the act of coughing. 

Finally, diphtheria, though so often communicated from person to per- 
son, not infrequently occurs de novo in a locality where the conditions are 
favoi-able for its development, and where it prevails as an epidemic or 
endemic. 

Anatomical Characters. — During an epidemic of diphtheria, and 
in localities where diphtheria is endemic, physicians often remark the prev- 
alence of a form of catarrhal pharyngitis, sometimes in so many instances, 
that it may be properly regarded as an epidemic. It occurs chiefly among 
young people, not infrequently affecting different children of a household. 
It has no premonitory stage, but commences somewhat abruptly with 
feter, which may be moderate but is often as great as in severe diphtheria. 
There is a sensation of dryness or fulness in the throat, with some pain in 
swallowing ; the face is flushed, and skin dry and hot, with lassitude, and 
in certain jDatients headache and nausea. The febrile movement is of short 
duration, subsiding in from one to three or four days. The temperature, 
which had perhaps risen three or four degrees, falls to the normal. 

If we inspect the fauces, we will observe a bright red color, either of the 
whole faucial surface or limited to a portion of it, which is usually the 
tonsillar region. There is little or no infiltration of the submucous con- 
nective tissue, and but little swelling of the tonsils and the adjacent lymph- 
atic glands. Within, a few hours after the commencement of the disease, 
small, circular, whitish spots or patches appear upon the tonsillar mucous 
membrane, some as small as a pin's head, and others a little larger. 
From six to a dozen may appear upon each side of the fauces, rising a 
little above the general level. They consist chiefly of epithelial cells and 
granular matter held together by tenacious mucus ; they can be readily 
brushed from the surface to which they adhere, for they do not penetrate 
the mucous membrane, and contain no fibrin. 

Within three or four days the redness begins to abate, and sometimes 
by the second day, the color of the patches changes to a dingy gray; they 
soon drop off, or ax^e brushed away by the ingesta, and within a week the 
patient has recovered. 

This malady has been designated catarrhal diphtheria. The micrococci 
occur in the patches, as they do in diphtheritic pseudo-membranes, as I 
have several times observed with the microscope; and the fact that this 
form of pharyngitis and diphtheria occur epidemically at or about the 
same time, indicates an identity or similarity in the conditions in which 
they originate. Nevertheless though I have observed many cases of this 
pharyngitis, I do not recollect an instance in which it has not passed off in 
the manner described, without any evidence of general infection of the 
system ; nor have I, or very rarely indeed, seen it pass into a croupous or 

16 



226 DIPHTHERIA. 

tliplitlieritic inflammation, although Oertel states that it occasionally does. 
Further, it does not appear to communicate diphtheria, nor diphtheria it, 
and therefore we seldom observe the two maladies occurring together in 
the same family. For these reasons it seems to me, that this epidemic 
catarrhal pharyngitis, having the anatomical character of whitish points 
or patches, as I have described them, and whose contagiousness is doubt- 
ful, should not be designated by the term diphtheria. If the expi-ession 
catarrhal diphtheria is retained, it is, in my opinion, only applicable to the 
two following conditions. Occasionally in a family, in which diphtheria 
is prevailing, we observe the fauces of a child who is in the commencement 
of the disease infected and swollen, for a day or two, sometimes for three 
or four days, before the pseudo-membrane appears. During this time the 
pharyngitis, though obviously diphtheritic, is catarrhal. Again, in a pa- 
tient, who has upon the fauces, or elsewhere, the croupous inflammation of 
diphtheria, we not infrequently observe a catarrhal inflammation of other 
mucous surfaces, as that of the tongue and sometimes of the nares. But 
the emjDloyment of the term catarrhal diphtheria, or catarrhal diphtheritic 
inflammation, to designate these conditions, seems to me to be an un- 
necessary refinement. I shall, therefore, make no further mention of catar- 
rhal diphtheria. 

Immediately in the commencement of diphtheria we observe redness of 
some portion of the raucous surface. In most instances, it is the faucial 
surface which is first aff*ected, and that part of this surface which covers 
the tonsils ; but it may be almost any other mucous surface, provided that 
it happens to be inflamed previously, or the primary inflammation may 
be upon some part of the skin where there is an open sore. If the first 
inflammatory manifestation of diphtheria is not upon the fauces, it is be- 
cause it is attracted elsewhere by an abrasion or sore of the surface. The 
inflammation rapidly increases in severity, and extends. The color of the 
inflamed surface is sometimes a deep, bright red, almost like arterial blood; 
in other cases it is dusky red, which indicates a vitiated state of the blood, 
and is an unfavorable prognostic sign. The dusky red color is most com- 
mon in secondary diphtheria. In a large proportion of cases in the course 
of a few hours the whole faucial surface is iuvolved in the inflammatory 
process. The mucous membrane of this part is thickened and softened ; its 
follicles tumefied, and actively secreting ; the uvula is elongated and en- 
larged from watery infiltration, and the submucous tissue also, to a certain 
extent, becomes involved in the inflammation and swells. The intensity 
as well as the extent of the phlegmasia varies, however, considerably in 
different patients. In a mild attack it is often limited to a part of the 
fauces, and in these cases there are few exceptions to the rule that the ton- 
sillar portion is affected, the redness gradually fading away in the healthy 
membrane beyond. The tousils also are tumefied, but less so than in ton- 
sillitis. If the pharyngitis is general, the passage through this portion of 



ANATOMICAL CHARACTERS. 227 

the digestive tube is diminished, but in most cases no more, and in many- 
children not so much, as in severe simple pharyngitis. 

Within a day, and usually within a few hours, from the commencement of 
the inflammation, a small slightly raised patch or spot is observed usually 
upon the tonsillar portion of the inflamed surface, of little importance, did 
the disease stop here, but very significant as a diagnostic sign, and as a fore- 
runner of what is to happen. This patch, termed the pseudo-membrane, 
gradually becomes firmer, and at the same time thicker and broader from 
fresh exudations underneath, and it has a grayish or grayish-white color. 
Sometimes different pointsor patches are observed, which extend and coalesce 
so that the fauces are almost entirely concealed from view. The pseudo- 
membrane is closely attached to the mucous surface, which it penetrates, 
becoming firm, and not easily detached. Attempts to separate it often 
lacerate the engorged capillaries, producing a free flow of blood. It does 
not ordinarily attain a greater thickness than one-eighth to one-sixth of 
au inch. I have seen it, however, not far from one-third of an inch thick. 
By the microscope we observe numerous micrococci with a small number of 
rod-like bacteria in the meshes of the exudation. They can be traced 
through the subepithelial tissues, being adherent to and even incorporated 
in pus-cells, and entering into and blocking up the minute lymphatic and 
bloodvessels. 

The same pseudo-membrane is often firmer in one part than another, the 
outer and central portions being more compact and tough for a time than 
that underneath, which is more recent, and in which there is less fibrilla- 
tion. After a few days, however, decomposition commences, and then that 
which was first formed, becomes softer than the more recent production. 
When this occurs, the color of the exudation changes from a whitish or a 
grayish-white to a dirty brown, and its exposed surface is uneven and 
jagged from the partial separation of shreds and fibres. 

The escape of the liquor sanguinis from the engorged vessels diminishes 
somewhat the turgescence of the inflamed tissue. If this is considerable, 
the pseudo-membrane often sinks below the level of the surrounding sur- 
face, producing an appearance very much like that of an ulcer, or even of 
gangrene. Though there is no loss of substance in this stage of the pseudo- 
membrane, it does, however, often occur, being produced by the presence 
and contraction of the fibrin with which the mucous membrane is in- 
filtrated. Sometimes the pseudo-membrane has a reddish tinge. This is 
due to rupture of the capillaries, and the escape of the blood-corpuscles. 
It occurs in those cases in which the inflammation is intense, and the cap- 
illaries are greatly engorged. Sometimes the lower part of the exudation 
is blood-stained, while the exposed surface has the usual grayish-white 
hue. For a very interesting and instructive description of the anatomical 
characters of the diphtheritic pseudo-membrane, the reader is referred to 



228 DIPHTHERIA. 

the treatise of Prof. Rindflei.sch, of Bonn, relating to pathological his- 
tology. His description is as follows : 

"Genuine diphtheritis has no claim to be regarded as a specific process 
in the same measure as croup. That which microscopically characterizes 
it, and has become the occasion of placing it as a membranous inflamma- 
tion is the formation of a whitish-gray, compact, felted membrane, which 
is elevated, perhaps, to the height of one-half line along the level of the 
mucous membrane, but penetrates just as deep into the substance of the 
mucous membrane, and is most intimately connected with the latter. This 
membrane is nothing that is superimposed, nothing secreted, but the mucosa 
itself, as far as it has been partly tumefied, partly rendered amemic, even 
by the excessive infiltration with cells. This condition has not improperly 
been compared with a mortification by a chemical agent, with a corrosion, 
and the diphtheritic membrane has been designated as diphtheritic scab ; 
in fact the diphtheritic membrane is a caput viortuum, it can undergo no 
other changes than those of putrefaction, of decomposition ; and the ques- 
tion only is, how it is loosened and removed from the intimate organic 
connection in which it stands wdth the mucous membrane. A sharply de- 
fined boundary line separates, as we can convince ourselves with the naked 
eye, the living from the dead ; but numerous connective-tissue fibres, blood- 
vessels, nerves, and elastic fibres, pass over from the living into the dead ; 
they must all have separated ere the loosening can proceed. The means 
which are placed at the command of the organism are inflammation and 
suppuration. We call this inflammation 'reactive,' and unite with it the 
idea as though this were an answer to the irritation, which the diphtheritic 
scab exerts upon the surrounding mucous membrane; yet a portion of the 
hypersemia also may be explained according to static principles as collateral 
fluxion. The pus collects between the scab and the healthy parts and al- 
ways, accordingly as the fibrous bridges mentioned melt down and tear, 
the separation begins now at the edges, then at the centre. After it is 
completed an ulcer remains behind which is disposed to rapid cicatriza- 
tion ; not unfi'equently, however, the process repeats itself again at the 
same place ; we have a new scab, and with it anew the necessity of a 
purulent separation, after whose termination a very considerable loss of 
substance remains. The cicatrices finally resulting distinguish themselves 
by their capacity of vigorous retraction, so that the danger of subsequent 
contraction of mucous membrane canals, especially of the large intestine 
after dysentery, threatens so much the more, the more diffused the ulcera- 
tion was." (Text-book of Pathological Histology, translated, page 354.) 

During the height of the inflammation it is astonishing often to see with 
what rapidity the diphtheritic membrane returns, when removed by force. 
A few hours often suffice to restore it as firm and extensive as before the 
interference. If the exudation is examined with the microscope as soon 
as it appears upon the faucial surface, it is seen to consist largely of cells, to 



ANATOMICAL CHARACTERS. 229 

wit, plastic nuclei and pus-cells mixed, with epithelia; with these elements, 
we find amorphous matter, and ordinarily delicate interlacing fibrillse. Sub- 
sequently fibrillation is more complete, and the false membrane consequently 
more firm and resisting. In feeble children fibrillation is sometimes lack- 
ing, or is so slight as not to be observed with the microscope. In these 
cases the pseudo-membrane is cellular and amorphous, and is easily de- 
tached. Such was its microscopic character in a case which occurred in 
the Nursery and Child's Hospital of this city ; the inflammatory product 
in this patient covered the raucous membrane of the stomach, as well as 
those parts which are commonly the seat of it. This case I shall allude to 
again. 

In favorable cases the false membrane is detached in a few days, and is 
either expectorated or swallowed with the ingesta. Its separation is pro- 
moted by the secretions underneath, especially by pus, which is formed in 
abundance between it and the surface on which it lies and which it pene- 
trates. In many, perhaps a majority of cases, however, it does not separate 
in mass, but by progressive liquefaction. A little less of the pseudo-mem- 
brane is observed at each visit, until it entirely disappears. Such are the 
appearance, character, and history of the pseudo-membrane in this disease. 
Its common seat is upon the fauces, and in mild cases it is ordinarily found 
there alone. Unfortunately all the mucous surfaces are liable to be at- 
tacked by the inflammation in consequence of infection of the blood, and 
therefore in severe cases, and even in cases of moderate severity, we often 
find this product elsewhere, as well as upon the fauces, and in localities 
where, from its mechanical effect, it greatly increases the danger, and even 
compromises life. The mucous membrane of the nostrils, mouth, larynx, 
trachea, oesophagus, stomach, conjunctiva, vagina, and even the delicate 
lining of the external ear, are at times the seat of diphtheritic inflamma- 
tion, with the characteristic product. If the exudation occur in the larynx, 
or air-passages below the larynx, we have the phenomena and result of 
true croup ; if upon a surface concerned in the digestive process, this func- 
tion is more or less interfered with. I have already alluded to a case 
which occurred in the Nursery and Child's Hospital of this city, in which 
patient the surface of the stomach was almost completely lined with the 
diphtheritic formation, so that the function of this organ was apparently 
nearly or quite abolished. The occurrence of the pseudo-membrane in 
the nares is common, and is attended by the discharge of thin mucus and 
pus; but though inconvenient to the patient, its mechanical effect is 
not dangerous, except in the nursing infiiut, in whom it interferes more 
or less with lactation. The thin irritating discharge produces excoriation 
around the nostrils and upon the upper lip. 

In mild cases of diphtheria, in which the pseudo-membrane is small and 
quite superficial, penetrating but little the mucous membrane on wliich it 
lies, there is little danger of septic poisoning. If on the other hand the 



230 DIPHTHERIA. 

inflammation is severe, and the exudation occurs not only upon, but in the 
mucous membrane, so as to cause obstruction in the bloodvessels in this 
membrane, and consequent ulceration, septicaemia is very apt to occur 
when the pseudo-membrane begins to decompose. The danger of this is 
apparent when we recollect that the minute lymphatic and bloodvessels of 
the mucous tissue penetrate the pseudo-membrane, and lie within the de- 
composing mass. Septicsemia is most apt to occur when the breath of the 
patient has become fetid, and the false membrane becoming dark gray, 
and breaking down, produces au ichorous discharge which flows from the 
mouth or nostrils. Usually in these cases blood escapes from the exposed 
vessels and mixes with the detritus. 

Absorption of the poisonous substance produces inflammation of the 
lymphatic vessels, along which it passes, and of the lymphatic glands, which 
.these vessels enter. The adenitis also gives rise to inflammation of the 
periglandular connective tissue, so that the neck is thickened, hard, and 
tender. Sometimes the depression between the cheek and shoulder is almost 
obliterated. 

Did absorption of the poison extend no farther than the tissues of the 
neck, the condition, though serious, would not be so generally unfavorable, 
but unfortunately the whole system is frequently poisoned, and various in- 
ternal organs become the seat of serious lesions, such as embolisms, infarc- 
tions, embolismal inflammations, and abscesses. These are a cause of death 
in certain patients who would otherwise recover. If we examine a gland 
which is swollen and inflamed by the toxic absorption, we will find that its 
bloodvessels are congested, and its cells have undergone hyperplasia. The 
periglandular connective tissue is oedematous, and sometimes infiltrated 
with lymphoid cell-nuclei and pus-corpuscles. Capillary haemorrhages are 
also common in the connective tissue, and micrococci are found in the 
lymphatic vessels, lymphatic glands, and in the connective tissue. 

A more minute examination of the internal lesions which have been ob- 
served in fatal cases, will aid us in understanding the cause of the gravity 
of the disease in those instances in which death occurs, or convalescence is 
tardy, although the pharyngitis and other external lesions are mild or have 
disappeared. 

In the air-passages the false membranes diflPer in some respects from those 
upon the faucial surfaces, the difference being due partly at least to the 
fact that they are lined by columnar epithelial cells. These cells, under 
the influence of the inflammation, losing their vibratile cilia, swell later- 
ally, and their nuclei also enlarge. Fibrin escapes between them upon 
their free surface, inclosing them in its meshes, or underneath them, de- 
taching them from the basement-membrane. The fibres of attachment of 
the false membrane to the mucosa and submucosa are more slender, and 
therefore the detachment is more easily effected in the air-passages, where 
the epithelia are columnar, than upon the fauces and other surfaces, where 



ANATOMICAL CHARACTERS. 231 

they are of the pavement variety. Thus at autopsies T have noticed 
the false membranes either already separated or but slightly adherent to 
the mucous surface below the vocal cords, while at the entrance of the 
larynx and in the pharynx it was intimately connected with the surface 
underneath. 

If death occur from obstruction in the air-passages the lungs will be 
found much reduced in size, the anterior superior portions being pale from 
lack of blood, and perhaps emphysematous, while the posterior and in- 
ferior portions have a dark-red color, many of the lobules being collapsed, 
and others not only collapsed, but in the commencement of catarrhal 
pneumonia. This difference in the state of different parts of the lungs in 
those who have died of suffocation in consequence of the presence of the 
false membrane in the air-passages, receives partial explanation from the 
seat of the exudation in the bronchial tubes, for in those who perish from 
this cause the exudation is found chiefly in such tubes as pass to the posterior 
and inferior parts of the organ, while such as pass to the superior and an- 
terior lobules remain free from it. In some instances, in parts of the lungs 
fibrin can be traced along the minute bi'onchial tubes into the alveoli, 
where it forms a network containing in its interstices pus, and sometimes 
blood-corpuscles, and more or fewer micrococci. Small extravasations of 
blood, which may be numerous and are attributed to the poisoned state of 
the fluid, often occur in the lungs in severe cases. 

In the more malignant forms of diphtheria, in which the blood is pro- 
foundly altered, and systemic poisoning has occurred, the pleural, pericar- 
dial, and even peritoneal surfaces exhibit numerous capillary haemorrhages, 
and the pleura and pericardium are sometimes inflamed. Extravasation of 
blood also occurs in these cases in the mucous membrane of the stomach, 
and less frequently in that of the intestines. The spleen is also slightly 
enlarged, with an increase of its cellular elements. 

The state of the kidneys is interesting, on account of the frequency of 
albumen, and casts in the urine in severe diphtheria. If the child die from 
diphtheritic laryngitis, and therefore from suftbcation, the kidneys are 
ordinarily hypereemic and a little enlarged in consequence. The hyper- 
semia is due to the mode of death, which causes venous congestion. 

If blood poisoning or septicaemia have occurred, the kidneys also present 
a deeply congested appearance, on account of which and the extravasa- 
tions, many of theMalpighian bodies cannot be clearly distinguished from 
the surrounding parts. They are often concealed from view by the ex- 
travasated blood, which has escaped from their vessels. In the Malpighiau 
tufts and the uriniferous tubes the most interesting changes occur. The 
epithelial cells swell and become more granular and opaque. In the more 
severe cases these cells, collecting in solid cylinders, nearly or quite occlude 
the canals. Occasionally blood flows from a Malpighian tuft into the 
uriniferous tubes so that they resemble small veins. In the condition of 



232 DIPHTHERIA. 

the kidneys in these grave cases there is abundant explanation of the oc- 
currence of blood-corpuscles, casts, and albumen in the urine, which are so 
frequently observed. The most frequent lesions observed in the brain and 
its meninges have been small extravasations of blood and clots, the largest, 
according to Buhl, having nearly the size of a pea. 

Symptoms. — As with other contagious diseases, the symptoms vary 
greatly in intensity in different cases. In general, in the commencement 
of an epidemic, diphtheria is more severe and fatal, and its symptoms 
more violent, than when the epidemic influence is abating. The promi- 
nent symptoms are, however, often disproportionate to the gravity of the 
attack. Striking examples of this fact might be given from cases in my 
practice, the friends not supposing that there was any serious ailment, 
and not seeking medical advice till the fatal termination had nearly ar- 
rived. Diphtheria corresponds, in this respect, with all those affections in 
which the blood is profoundly altered. 

The symptoms in the commencement are often mild. There is a degree 
of chilliness, with rigors, often slight, but lasting several hours, wiiich is 
succeeded by more or less fever, headache, languor, and loss of appetite. 
Still, the patient, if old enough, continues to walk about as if affected 
with a slight and temporary ailment. The symptoms are like those of a 
cold, for which, indeed, the initial stage of diphtheria is often mistaken. 
With many, one of the first symptoms is slight tenderness or a sensation 
of fulness in the fauces. A distinguished clergyman of the Pacific coast, 
who fell a victim to this disease, dreamed, a few nights before he com- 
plained of illness, that his throat was cut. Doubtless the diphtheritic 
inflammation had already commenced, so that what seemed a forewarning 
had a natural explanation. So insidious was the commencement in this 
case that the disease had advanced beyond all hope of relief when medical 
advice was first sought. 

In other cases the invasion is more abrupt and severe. Great febrile 
reaction, headache, pain in the ear, aching of the limbs, and loss of 
strength, compel the patient to take to bed from the first. Delirium may 
be present, but it is unusual. 

The symptoms of invasion have but little prognostic value. I have 
met cases with a severe commencement, attended by delirium, which ter- 
minated in complete restoration to health in less than a week, the presence 
of the membrane upon the fauces, and the occurrence of diphtheria in 
other members of the family, rendering the diagnosis certain. On the 
other hand, the milder commencement frequently ushers in a fatal form 
of the disease. 

The slight soreness of the throat or sensation of fulness, which accom- 
panies the initial stage of diphtheria, does not ordinarily become any 
more severe during the course of the attack, and it often disappears within 
a few days. The pain on swallowing, and the tenderness when pressure 



SYMPTOMS. 233 

is made upon the throat, are usually less than in quinsy or simple pharyn- 
gitis. The absence or mildness of local symptoms is the main reason why 
the disease is so often overlooked in its first stages. I have known more 
than once, in consequence of the slight tenderness in the throat, the large 
external swelling to be mistaken for some other ailment, till an incurable 
stage of the affection was reached. I was once asked to see a little girl 
about ten years old, on account of this external swelling, which was lim- 
ited to one side, and the character of which the parents did not understand. 
A physician, visiting near by a few days previously, had been asked to 
see this patient, and, without examining the fauces, attributed the swelling 
to inflammation of the root of a tooth, and had not thought it necessary 
to repeat his visit. This child, now within three. or four days of her death, 
was walking about, not complaining of her throat, but with poor appetite, 
and with the pale, cachectic aspect so common in advanced diphtheria, 
and having severe inflammation of the fauces, with a thick and firm 
pseudo-membrane extending from the pharynx forward to the arch of the 
mouth. The mildness of subjective symptoms was strikingly shown in 
another case which came to my notice. A little girl had been ailing a few 
days, and had swelling on both sides of the neck, but continued about the 
house and amused herself with playthings, even jumping the rope a few 
times on the day of her death. Finally, she sank rapidly of exhaustion, 
dying before a physician could arrive. These sudden and unexpected 
deaths in diphtheria are due to the profoundly altered state of the blood. 
If the inflammation invade the larynx, then the symptoms are immedi- 
ately conspicuous and alarming. 

The tongue in diphtheria is covered with a moist fur ; sometimes more 
or less of the exudation appears upon it; the appetite is poor; bowels 
regular. The pulse in different cases varies greatly in volume and fre- 
quency. It is often full and strong in the first days of the disease, but in 
the latter part, when death from blood poisoning approaches, it is feeble and 
slow. At first there are no marked symptoms referable to the respiratory 
apparatus. There is only that degree of acceleration of respiration which 
corresponds with the amount of fever. In many cases, favorable as well 
as unfavorable, there is no cough and no embarrassment of respiration 
throughout the entire sickness, though the inflammation of the faucial 
surface may be general and severe, and the constitutional disturbance 
very decided. But ordinarily, in the course of a few days from the incep- 
tion of the disease, the swelling of the nasal mucous membrane, and the 
occurrence of exudation upon it, produce snuffling respiration. The pres- 
ence of the phlegmasia upon the laryngo-tracheal surface is indicated 
by hoarseness of the voice and an occasional dry cough, and as the in- 
flammation extends and the pseudo-membrane forms, the cough becomes 
more frequent and harsh or raucous, as in true croup. Indeed, the condi- 
tion of the patient, as regards the larynx and trachea in diphtheria, when 



234 DIPHTHERIA. 

they are covered with a pseudo-membrane, resembles that in true croup. 
As the inflammation in the larynx and trachea, when accompanied by 
fibrinous exudation, is rarely amenable to treatment, the symptoms of 
obstructed respiration become more continuous and severe as the disease 
advances, till finally the dyspnoea is extreme; the inspiration is protracted 
and whistling, and accompanied by depression of the ribs; the counte- 
nance is anxious and pallid, the prolabia and fingers livid, and the little 
patient in vain seeks for relief by change of position. Occasionally, by 
great effort on the part of the child, or by fortunate treatment, a portion 
of the pseudo-membrane is expectorated, and for some hours there is ap- 
parently marked improvement, but it is only in exceptional cases that the 
membranous formation is not speedily and fully reproduced. As death 
draws near the cough diminishes both in frequency and force. 

In cases of a severe type the breath is ordinarily offensive, having a 
gangrenous odor. Thei'e is in such patients intense pharyngitis, with a 
pseudo-membrane which, from its low vitality, rapidly undergoes decay 
and also great external swelling from the adenitis and cellulitis. 

An efflorescence is sometimes observed upon the surface during the 
period when the temperature of the skin is exalted. This rash does not 
differ from ordinary erythema, so common in the febrile and inflamma- 
tory affections of infancy and early childhood. It is not attended by the 
minute papulae which produce roughness of the surface in scarlet fever. 
It is the erythema fugax of dermatologists suddenly appearing, and after 
some hours as suddenly disappearing. In many patients it is ab.sent, and 
it is seldom if ever observed, except in the first days, when there is an 
active circulation. 

The symptoms pertaining to the nervous system, which are ordinarily 
most prominent, I have already described. I have described the cephal- 
algia and muscular pains which are present in the initial period, but they 
soon abate. Convulsions may occur in young children, but not oftener 
than in other diseases attended by febrile reaction. 

The temperature is in most cases less than in scarlet fever; the fever 
abates in a few days, and in advanced stages of the disease the heat 
of surface is natural or less than natural. There have not been many 
chemical examinations of the urine in this disease, but in a few which 
ha.ve been made (Sanderson, British and Foreign Medico-Chir. Rev., Jan- 
uary, 1860) the quantity of urea excreted daily was found to be consider- 
ably more than when convalescence had commenced. The most interest- 
ing and important change, however, in the constitution of the urine, is 
the occurrence of albumen in it. This element was first discovered by 
Mr. Wade, of Birmingham, in 1857, and since then various observations 
in diflferent epidemics and localities establish the fact that albuminuria 
occurs in the majority of cases of severe diphtheria, and in many of a 
mild form. It often occurs at an early period, but in other patients it 



SYMPTOMS. 235 

does not appear till the close of the first week or comroencement of the 
second. It continues three or four days to as many weeks, when in favor- 
able cases it gradually becomes less and soon disappears. While albumi- 
nuria is more common in diphtheria than in scarlet fever, the quantity of 
albumen in the urine is ordinarily less than in that disease. The albumi- 
nuria of diphtheria is further distinguished from that of scarlet fever in 
the fact already stated, that it ordinarily occurs in the midst of the dis- 
ease, and is attended by slight anasarca, often by none, whereas in scarlet 
fever it occurs after the subsidence of the fever, is attended by greater 
anasarca, and even serous effusion in the cavities. If we examine the 
albuminous urine of diphtheria with the microscope, we find in it fibrinous 
casts and altered renal epithelial cells. These cells are opaque or granu- 
lar, mainly from the deposit of fatty particles in their interior. But this 
appearance of the cells is not peculiar to diphtheritic albuminuria. 

Occasionally there is a considerable amount of albumen in the urine in 
cases which are not severe, and the quantity in the same patient may vary 
from day to day. In some grave cases of diphtheria the urine is scanty, 
and there is then danger of ursemic poisoning. If there is great and con- 
tinued deficiency, death may occur from this cause in convulsions and 
coma. 

The course of diphtheria, like the intensity of its symptoms, varies 
greatly in different cases, whether the result be favorable or unfavorable. 
Complete recovery may occur within a few days, less indeed than a week, but 
in other and a considerable number of favorable cases weeks elapse before 
the health is completely restored. When the disease is so protracted, the 
pseudo-membrane is detached slowly, or, being detached, it is reproduced 
again and again. In these lingering cases the countenance bears the ap- 
pearance of marked cachexia, the appetite remains poor or capricious, 
the features are pallid, the body more or less wasted, and the strength 
reduced. Convalescence of such patients is slow and protracted, even 
after the inflammation has entirely disappeared. 

The course of diphtheria lacks uniformity in fatal not less than in 
favorable cases. I have known death to occur in a robust child of two 
years and three months on the fourth day, without cough, and entirely 
from the malignant nature of the affection. The strength was overpow- 
ered, and life so suddenly extinguished by the intensity of the diphtheritic 
virus. In this case there was great external swelling and intense pharyn- 
gitis. In another instance a girl of eleven years died on the third day in 
a sin)ilar manner. In other cases, as has been previously stated, death 
occurs from diphtheritic croup. In other, and a large proportion of fiital 
cases, the disease is more protracted. Without embarrassment of respi- 
ration, and often apparently with but moderate inflammation, the patient 
gradually loses flesh and strength. The face presents a pallid and ca- 
chectic aspect, and sometimes there is a general flabby or edematous 



236 DIPHTHERIA. 

appearance; the appetite is poor, and is improved but little by tonics ; 
the pulse is accelerated, and is day by day more feeble, till, finally, death 
occurs from the blood change. In these lingering and dubious cases all hope 
of recovery is sometimes dissipated by the occurrence of abundant hemor- 
rhage from the throat, in consequence of detachment of the pseudo-mem- 
brane and consequent rupture of the capillaries, or possibly sometimes 
from ulcers in the throat. I was once treating a little girl about nine 
years old with diphtheria, accompanied by pretty severe pharyngitis, and 
she had entered the third week, with prospect of a favorable issue of the 
disease, when she was suddenly seized with profuse hsemorrhage from the 
fauces, which was repeated, and death occurred in forty-eight hours. 

Probably, however, in New York, since the appearance of diphtheria in 
1858, one-third, and perhaps a larger proportion of the deaths from this 
malady, have been due to suffocation in consequence of the formation of a 
false membrane in the air-passages. Diphtheritic laryngo-tracheitis does 
not often occur as the primary manifestation of the malady, but it is pre- 
ceded by a pseudo-membranous pharyngitis, with or without coryza. Oc- 
casionally, however, in true diphtheria, the exudation of fibrin occurs only 
upon the surface of the air-passages below the epiglottis, while the fauces 
present only an inflammatory reddening, and the surface of the nares is 
either free from disease or only reddened. Thus, in January, 1875, I 
attended a child, aged two years and ten months, who died from a gradu- 
ally increasing dyspnoea after a sickness of four days, having during his 
sickness moderate swelling of the tonsils, and general redness of the faucial 
surface, but without fibrinous exudation upon it. The symptoms and his- 
tory of the case were precisely those of true croup, but the diphtheritic 
nature of the malady was clearly shown by the occurrence very soon after 
the death of the patient of diphtheritic pharyngitis, with abundant fibrin- 
ous exudation upon the fauces, of the two young women who nursed him. 

Sequelae. — Those who recover from a severe attack of diphtheria, re- 
main often for weeks with a pale and cachectic appearance. The blood 
is evidently profoundly altered, so that there is a deficiency of red cor- 
puscles or a state of spaneemia, which slowly disappears. This is a com- 
mon result of protracted constitutional diseases, but it is more noticeable 
after this than most kindred affections. The excretion of albumen from 
the kidneys no doubt increases materially the impoverishment of the blood. 
Blood poisoning, whether eflfected through the agency of the micrococci or 
not, which is so common in severe cases, also greatly impairs the nutritive 
process. Even the nutrition of the micrococci in the lymph and blood- 
vessels must, in proportion to their number, diminish the richness of the 
blood, and consequently the nutrition of the tissues. 

There is another sequel, which possesses great interest, as it is common 
in diphtheria, and as its etiology is not fully understood. This sequel is 
paralysis. Paralysis does not occur till after the abatement of the in- 



SEQUELS. 237 

flammatory symptoms. The patient seems fully convalescent. The fever 
has ceased ; the appetite is returning ; the anaemia is becoming less, and 
there is prospect of speedy restoration to health, when this nervous aifec- 
tion is developed. The interval between the subsidence of the inflamma- 
tion and the commencement of the paralysis is usually two or three weeks. 
The muscles most frequently affected are those of the pharynx, so that 
deglutition is rendered difficult, to such a degree often, that nutrition is 
seriously interfered with. The aliment taken passes back through the 
nostrils, or is not swallowed till after several successive eiForts. In the 
attempt to swallow, a portion of the food sometimes enters the larynx, so 
as to produce violent coughing. As we observe the dysphagia, it seems as 
if there must be pharyngitis, which renders deglutition difficult, but on 
inspecting the fauces we find no evidences of inflammation. The mucous 
membrane has recovered its normal appearance, and the nerves only are 
affected. The velum palati hangs flaccid and motionless, like a curtain. 
In some there is only pharyngeal paralysis, but in many the loss of muscular 
power occurs in other parts. Whenever it occurs elsewhere, the pharyngeal 
muscles are neai'ly always involved at the same time. Diphtheritic pa- 
ralysis may affect the motor muscles of the eye, causing strabismus ; the 
muscles of one side, causing hemiplegia ; of the legs, causing paraplegia ; 
or of an arm on one side and leg on the opposite. It does not com- 
mence simultaneously in the various muscles which are affected, but in 
succession, those first affected being for the most part the muscles of the 
pharynx. In some the muscles of the bladder have been paralyzed, lead- 
ing to retention of urine or difficulty in passing it. Paralysis in the limbs 
is frequently preceded by tingling or a sensation of formication. There is 
often not a total loss of sensation or of motion in the paralyzed part, but 
there is numbness with great difficulty rather than impossibility of motion. 
A few cases have been reported in which the paralysis was almost general, 
and some believe that they have met cases in which the heart was par- 
alyzed, death occurring suddenly and unexpectedly. Dr. J. B. Reynolds 
relates a case in the Neiv York Journal of Medicine, May, 1860, in which 
there was not only strabismus, partial paralysis of the limbs, and paralysis 
of the muscles of the pharynx, so that food was regurgitated, but the head 
dropped forward so that the chin rested on the sternum, 

A majority of these affected with paralysis recover, although few regain 
the complete use of their muscles in less than one month, and many do not 
till between two and four months. 

Defect of vision is an occasional result of diphtheria ; some have pres- 
byopia ; others myopia ; some see double; some are amaurotic; while in 
others one pupil is more dilated than the other, or both pupils are dilated, 
and feebly sensitive to light. Tliis impairment or perversion of vision 
gradually disappears as the vigor of system returns. 

Pkognosis. — The prognosis in diphtheria is more favorable when it 



238 DIPHTHERIA. 

occurs sporadically, or at the close of an epidemic, than when the epidemic 
influence is prevailing. Its gravity is in a majority of cases proportionate 
to the local svmptoms. Therefore, intense pharyngitis, an extensive pseudo- 
membrane, and great cervical cellulitis and adenitis, indicate a form of the 
disease which usually proves fatal in the robust as well as weakly. Since 
these inflammations of the neck indicate absorption of the poison, infection 
of the system may be regarded as inevitable where they occur, and this is 
ordinarily fatal. When the inflammation extends to the larynx, and the 
phenomena of croup arise, there is slight prospect of recovery. Pseudo- 
membranous pharyngitis is then present in addition to the depressing in- 
fluence of the diphtheritic virus. True croup Ave know to be ordinarily 
fatal, and more unfavorable, evidently, is the prognosis if a similar condi- 
tion occur in diphtheria. When the croupy cough, voice, and respiration 
are observed, he will seldom err w^ho predicts a fatal result within a week, 
and often death follows in two or three days. 

Great acceleration of the pulse continuing after the first week, a 
countenance pallid, with softness or flabbiness of the tissues, the occur- 
rence of hgemorrhage from the fauces or other parts, -are prognostic of an 
unfavorable ending. The secondary form of diphtheria is more apt to 
prove fatal than the primary, in consequence of the depressing eflfect of 
the antecedent disease. 

From what has already been stated, it is obviously injudicious to predict 
a favorable or an uuftivorable termination from the character of the initial 
symptoms, since an obstinate and fatal case often commences mildly, and 
cases easily managed may commence with violent symptoms. But if the 
inflammations, mucous and glandular, remain of a mild grade, if the 
strength is not greatly impaired and the constitution is good, and there 
are no laryngeal symptoms, a good result is highly probable. 

In many cases, after the active symptoms have somewhat abated, the re- 
sult for days or even weeks is uncertain on account of the altered state of 
the blood, and the presence of internal lesions, especially those of the kid- 
neys. If there is no serious internal lesion recovery is probable even with 
great impoverishment of the blood. Diphtheritic paralysis may continue 
several weeks or months before recovery. 

Diagnosis. — In most instances the diagnosis of diphtheria is readily 
made when the case has continued a few hours, for the characteristic false 
membrane is observed on inspecting the fauces. I have usually at my first 
visit been able to state the nature of the pharyngitis from the appearance. 
But there are cases which vary from the typical form in which the 
diagnosis is more or less diflicult. The confervoid growth of sprue, 
when occurring upon the fauces is sometimes mistaken for the false mem- 
brane of diphtheria, but the error of mistaking one for the other in cases 
which I have met, has been due to hasty and careless examination rather 
than to any real difficulty in the discrimination. The peculiar product of 



DIAGNOSIS. 239 

the sprue has but little depth and cohereuce, and is readily detached 
without injury to the mucous membrane or its vessels. If there is any 
doubt, the differential diagnosis can be readily made by the microscope. 

The diagnosis of diphtheria from true croup is sometimes difficult when 
the prominent lesion is in the larynx. Diphtheritic laryngitis is usually ac- 
companied by more tumefaction of the lymphatic glands of the neck, and 
more discharge from the nostrils. Moreover, as already remarked, the laryn- 
gitis is commonly secondary in point of time to the pharyngitis, so that in the 
first day of the former we observe so much faucial inflammation, and faucial 
pseudo-membrane, that it has evidently been the first and predominant in- 
flammation, whereas in true croup the laryngitis precedes and predominates. 
Nevertheless, as we have stated, it does seem that during an epidemic of 
diphtheria cases which have the clinical history and anatomical characters 
of ti-ue croup in their beginning, not infrequently pass into a diphtheria, 
a change which is so common in certain specific inflammations, especially 
in the pharyngitis of scarlet fever, and is sometimes observed in ex- 
ternal inflammations, which are not of a specific character as in the three 
cases already alluded to, in which trachoma passed into diphtheritic con- 
junctivitis. Thus a boy, aged two years and ten months, died of acute 
laryngo-tracheitis, lasting about four days. He lived in the suburbs of 
the city, where the houses were scattered, and where there had been no 
recent diphtheria, although this malady was very prevalent in the city. 
The case commenced with hoarseness, which gradually increased to a fatal 
obstruction in the air-passages, without any pseudo-membrane upon the 
fauces or upon any other visible part. This case seemed to be identical 
with the true croup with which we were familiar before the occurrence of 
diphtheria in New York; and yet if such were its nature in its commence- 
ment as seems probable, it became diphtheritic, for two or three days after 
the death of the child, the two young women who nursed him were 
affected with severe diphtheritic pharyngitis with the characteristic pseudo- 
membrane. While, therefore, we recognize a membranous croup which is 
entirely distinct from diphtheria, if the former, as seems to be the case in 
New York, seems less frequent in a locality where diphtheria becomes 
endemic, than it was prior to the occurrence of diphtheria, the explanation 
of the difference in its frequency is probably the fact that, in a certain pro- 
portion of cases, croup becomes identified with diphtheria. But we have 
already dwelt upon this point in a preceding page. 

Sometimes the occurrence of albumen in the urine with or without 
fibrinous casts, aids in establishing the diagnosis, for albuminuria is com- 
mon in diphtheria and rare in croup, la doubtful cases, which prove 
fatal, it might be supposed that the post-mortem examination would in- 
dicate the exact nature of the disease, but even with this examination, 
differential diagnosis is not always possible, for although the pseudo-mem- 
brane of diphtheria when in its usual seat, namely, upon the fauces, is 



240 DIPHTHERIA. 

more or less blended with the mucous membrane, this intimate relation 
is much less marked in the larynx and trachea, as has been stated above. 
I have been able to peel off the membrane from these surfaces in un- 
doubted diphtheria precisely as in croup, so that had it been limited to 
them, as is sometimes the case, the anatomical characters would not have 
sufficed for the diagnosis. It is evident from the above facts, that the 
diagnosis of diphtheria from croup, though easy in typical cases, from the 
anatomical characters, and from the history of contagiousness, may in 
isolated cases be difficult if not impossible. 

The diagnosis of the milder forms of diphtheria from simple catarrhal 
pharyngitis is obviously easy, if we limit the term diphtheria to those cases 
in which a pseudo-membrane occurs. But if we include under the term 
diphtheria all those cases of pharyngitis which are apparently due to the 
epidemic influence, but in which the inflammation is catarrhal, and re- 
mains such, then positive and accurate diagnosis is often impossible. 

The diagnosis of diphtheria from scarlet fever is based on the fact that 
the latter malady commences ordinarily with vomiting, and is attended 
by an efflorescence, while there is no fibrinous exudation upon the fauces, 
unless, as so frequently happens, diphtheria occur as a complication. 

Treatment. — It is obvious, if the views expressed in regard to its 
pathology are true, that the early topical treatment of diphtheria is of the 
utmost importance. Whatever may be our opinion in regard to the nature 
and causes of diphtheria, clinical observations teach us that the gravity of 
this malady is in most instances proportionate to its local manifestations, 
at least in the commencement of the disease. Now we certainly have it 
in our power to control greatly these manifestations, namely, the diphther- 
itic inflammations, diminishing their extent and intensity, and checking 
or diminishing the fibrinous exudation. If, by our treatment, we can 
limit the exudation to a small surface, or can remove it so that the in- 
flammation from croupous becomes catarrhal at an early stage of the 
malady, the patient is probably safe! This is a general fact in reference 
to the treatment of diphtheria, which is abundantly established by clinical 
experience, and which of itself justifies local treatment designed to moderate 
the inflammation. But there are certain special benefits to be derived from 
local remedies which are so important, that in my opinion no one can prop- 
erly treat diphtheria who does not fully appreciate them. Both clinical 
observations and experiments on animals have shown us that the diphther- 
itic pseudo-membrane contains the specific virus in a very inoculable and 
energetic state, and the air as it passes over the membrane becomes more 
or less impregnated with the poison. Hence the source of the great danger 
which exists, not only of the communication of the disease to others, but 
of auto-infection, for it can hardly be doubted that diphtheritic laryngitis, 
to which patients are so liable, not infrequently originates from a trans- 
ference of the virus from the surface of the pharynx to that of the larynx 



TREATMENT. 241 

during inspiration. Prompt treatment, therefore, of the fauces or of the 
nostrils by disinfectants is the most reliable means which we possess of 
preventing the occurrence of that fatal form of diphtheritic inflammation, 
namely, the laryngeal, in one who has diphtheria. 

Another object which we may expect to accomplish by local treatment, 
if the inflammation is upon a surface which is accessible, is the prevention 
of blood-poisoning, whether this poison is the bacteria, or a secretion of the 
bacteria, or a substance which is developed independently of these organ- 
isms, though associated with them. Since I have inspected the fauces more 
carefully and frequently in scarlet fever and diphtheria, and have made 
use of local treatment whenever any whitish substance secreted or exuded, 
appeared over the tonsils, I have much less frequently observed extensive 
swelling along the sides of the neck, which, as we have said, originates from 
and indicates the passage of the poison along the lymphatics of the neck 
into the system, and which is therefore so generally prognostic of an un- 
favorable ending. 

In certain cases the proper employment of local measures, even when the 
inflammation is upon a surface which in ordinary instances it is easy to 
treat, is difiicult or impossible. Thus in my practice, a little girl of eleven 
years died after a sickness of only four days, with no treatment or even 
inspection of the fauces, on account of the fierce resistance which she made ; 
and cases are more frequent of difficulty in the proper treatment of the 
nostrils. But such instances are exceptional. Ordinarily with a little tact, 
and with the use of a proper instrument, the application can be made 
quickly and sufficiently to either the faucial or Schueiderian surface. 

Local treatment should not be painful. The day of escharotic and pow- 
erfully irritating applications to the throat has passed, and the expression, 
" burning the throat," so often heard in families, is a misnomer as applied 
to the treatment of the present time. It is ordinarily best not to attempt 
to tear off" the membrane, for its forcible separation irritates the inflamed 
surface, and promotes hsemorrhage. Whichever disinfecting substance we 
employ, should be applied in such a way that it penetrates the pseudo-mem- 
brane, and if possible touches and bathes the surface underneath, I prefer 
making the application with a large camel-hair pencil rather than with 
the sponge, which is more irritating and which applies a less quantity of 
liquid to the fauces. 

Unfortunately, in many instances in private practice the full benefit of 
local treatment cannot be obtained, because the physician is not summoned 
till the malady has continued for a day or more, and the system is perhaps 
infected at the time of his first visit. In order to ascertain the full benefit 
which can be derived from such measures, statistics should be obtained of 
cases treated from their commencement, or within a few hours from their 
commencement. Such statistics are furnished by the Catholic Foundling 
Asylum of this city. Diphtheria has prevailed in this institution during 

16 



242 DIPHTHERIA. 

1874, and up to the present time (June 1st) in 1875. Tlie Sisters, having 
had more than a year's constant experience with the disease, detect the 
initial symptoms, examine the fauces, and have commenced the local and 
geuei-al treatment before the daily visit of the physician. In this institu- 
tion in the first five months of 1875 thirty-two cases of diphtheria occurred, 
and of these cases only six died ; three of laryngitis, and three of blood- 
poisoning. One of the six fatal cases ought in fairness to be exchided from 
the statistics, as it was admitted into the asylum on the sixth day of the 
disease. Possibly now and then a case might have been under treatment 
which was not true diphtheria, but a large proportion of the cases I saw 
and examined myself, and even if the doubtful cases were rejected it would 
not materially change the proportion of recoveries. 

I will briefly outline the mode of treatment employed with so good a 
result in the Foundling Asylum, and by which in my private practice 
during the last year I have certainly saved a much larger proportion of 
cases than I had been able to cure by any other measures which I had 
previously employed. 

As soon as the ease comes under observation the following mixture is 
applied every second or third hour over the fauces by one or two applica- 
tions of a large camel-hair pencil : 

R. Acid, carbolic, gtt. vj-x. 

Liq. ferri subsulpbatis, ^iij. 

Glyceriniu, ........ ^j. Misce. 

If there is discharge from the nostrils indicating diphtheritic inflamma- 
tion of the Schneiderian membrane, a little of the same mixture diluted 
with an equal quantity of warm water is injected into each nostril every 
three to six hours. In doing this the child is placed upon its back, with 
the head thrown backward and the eyes covered by a towel, to prevent the 
liquid from entering the eyes. A small glass ear or nostril syringe, with a 
knob or button at the end of the nozzle, is the best form of instrument for 
these injections. One-third to one-half of a teaspoonful of the diluted mix- 
ture is a sufficient .quantity to employ for each nostril. This application 
properly made, prevents decomposition, removes the oflfensive odor, and, 
which is of the greatest importance, prevents blood-poisoning ; it imme- 
diately arrests the movements of the bacteria, and probably destroys them, 
as I have observed in experiments with the microscope. 

Quinine, in doses of one to two grains, according to the age and severity 
of the case, is administered about every fourth hour, and each hour in the 
interval half a teaspoonful to one teaspoonful of the following : 

R. Potas chlorat., 3J-ij. 

Tine, ferri chlorid., 3J. 

Syr. simplic, Jiv. Misce. 

A little chlorine is set free in the above mixture, and the quantity may 



TREATMENT. 243 

be increased by adding a few drops of dilute muriatic acid. No drinks 
are- allowed for a few minutes after its administration as well as after the 
use of the brush, so as uot to wash it away too quickly from the fauces. 

In three or four days, if the case progresses favorably, these remedies 
are employed less frequently, but they are not discontinued until not only 
the pseudo-membrane has disappeared, but the inflammation has in great 
part abated. For not infrequently the fibrinous exudation reappears after 
it has been totally removed, if the pharyngitis remain. Thus I have 
known it to reappear after it had been absent an entire week, or even 
longer. Hence also the need of daily inspection of the fauces until con- 
valescence is well advanced. When the inflammation has begun to abate, 
and there is no reappearance of the exudation, a gargle or drink of chlo- 
rate of potash in water usually suffices for topical treatment. 

Such is the treatment, substantially, which has proved so successful in 
the Foundling Asylum. From my observations of its effects, not only 
within this institution, but in private practice, I can confidentially recom- 
mend it. 

The employment of tonics, especially of quinia and iron, in the treat- 
ment of diphtheria, is almost universal in the profession. Our reliance 
must be upon these agents in those cases in which the system is infected 
from the first or from an early date, more than upon topical remedies. 

Thus one of the fatal cases in the Catholic Foundling Asylum was a 
girl aged 3 J years, who sickened with diphtheria on March 25th, 1875. 
On the 26th her pulse was 160, temperature 102?°, and a diphtheritic 
patch had appeared over the right tonsil. On the 28th there was a free 
muco-purulent discharge from the nostrils, with a temperature of lOOf °, 
and a pulse of 128. The features were pallid and flabby, presenting the 
appearance of profound cachexia. On this day free epistaxis occurred 
after the use of the syringe, although it was employed gently ; subse- 
quently repeated hsemorrhages occurred. On March olst the skin was 
cool ; although milk-punch was liberally employed, the temperature was 
101° and the pulse 88. Death occurred April 1st from the cachexia. 
Her cough throughout was slight, and the respiration without embarrass- 
ment. At the autopsy the mucous membrane of the larynx, trachea, and 
bronchial tubes was found uniformly and greatly injected, but without 
any fibrinous exudation ; lungs healthy, except quite large extravasations 
of blood in the posterior part of one lung ; appearance of heart normal, 
and small clots in each of its ventricles ; other organs of the trunk (spleen, 
liver, kidneys, etc.) apparently normal : urinary bladder contracted aud 
nearly empty. The urine in this case, which was examined a day or two 
before death, either contained no albumen or only a trace. The connective 
tissue behind the angles of the lower jaw, which had been tumefied during 
life, presented a deep red color ; also with extravasations of blood. The 
spleen and half a kidney, placed in a solution of bichromate of potash 



244 DIPHTHERIA. 

immediately after tlicir removal from the body, were examined micro- 
scopically by Dr. Heitzmann, but no bacteria or anything abnormal was 
discovered in them. In cases like the above, local treatment, however 
early employed, will probably fail to prevent contamination of the sys- 
tem, either because this has already occurred before the inflammations 
occur, and the disease is manifested, or because the inflammation from 
which the system becomes infected is upon a part which is concealed from 
view, and is not therefore detected and treated sufficiently early. But as 
such cases are exceptional, they furnish no argument against the employ- 
ment of local measures in the treatment of ordinary diphtheria. 

When the inflammations abate, and the pseudo-membrane no longer 
reappears, if the patient is not speedily restored to health the poison has 
entered the system. Pallor, loss of strength and appetite, flabbiness of 
the flesh, haemorrhage, etc., indicate a profound blood-change, and now 
our main reliance must be on stimulants and tonics, with the most nutri- 
tious diet. 

Laryngitis may occur in the course of diphtheria without any marked 
symptoms referable to the larynx, provided that the inflammation remain 
catarrhal, as in the case related above. But if fibrinous exudation occur 
in the larynx, symptoms of obstructed respiration are developed, and the 
condition is then one of imminent peril. Prompt measures are required 
to relieve the patient, but the result will probably be unfavorable, as we 
have already stated. It will be necessary sometimes to prescribe one of 
those emetics which are but slightly depressing, as sulphate of copper, but 
even this should be administered with an alcoholic stimulant. Depress- 
ing emetics, as ipecacuanha and hive syrup, should be avoided. I have 
known sudden fatal prostration to occur after the use of the latter under 
such circumstances, in a strong child of eight or nine years. Quinine, 
steam as recommended in the treatment of croup, chlorate of potash, and 
muriate of ammonia, with alcoholic stimulants, are the remedies for diph- 
theritic laryngitis which will be found most useful. 

Diphtheritic paralysis requires the use of strychnine with tonics. I 
ordinarily employ the elix. phosphat. ferri, qui, et strychuise of the shops. 
Each drachm of this contains gr. g',, of strychnia, and by dilution with 
water the proper dose can be administered to a child of any age. Thus, 
recently, a child aged six years, having paralysis of the muscles of the 
pharynx, recovered in about one week, by the use of one drachm of this 
medicine daily, given in four or five doses. I have not found it necessary, 
in any case which I have observed, to employ electricity, but it is no 
doubt useful in expediting recovery, especially if the paralysis is in the 
limbs. The ana?mic state which succeeds diphtheria requires the use of 
iron for several weeks. 

Preventive Measures. — The diphtheritic virus, like the scarlatinous, 
may remain for weeks or mouths in a locality, or in apartments, notwith- 



PREVENTIVE MEASURES. 245 

standiijg the use of the ordinary disinfecting and sanitary measures. In East 
Fifty-fifth Street two families resided in a brown-stone house, the sanitary 
condition of which was apparently good. In December, 1874, diphtheria 
occurred in one of these families, who occupied the lower floor and the 
basement, causing the death of two of the children. The other family, in 
order to escape the danger, immediately removed to another part of the 
city, where they remained two months, returning home on March 6th. 
On March 14th and 15th, eight and nine days after the return, their two 
children, aged 2i and 4? years, who had been allowed free access to the 
room in which the fatal cases had occurred, also took severe diphtheria, 
one of them dying. 

In another family, living in the suburbs of New York, the mother con- 
tracted diphtheria from her brother's child, who died of the malady a few 
blocks distant. Returning home, she occuijied a small room, remaining 
constantly in it, and by prompt local treatment was soon convalescent. 
Her only child, a boy of six years, was excluded from her companionship 
about one month, after which he was allowed to enter the room, and slept 
in it. Within a few days, namely, thirty-five days after it commenced in 
the mother, the diphtheritic patch appeared upon his fauces. In one of 
the asylums of this city, diphtheria has been pi-evailiug more than a year, 
the cases occurring mainly in one of the buildings, and with so little break 
or intermission that it appears that the diphtheritic virus has not been 
eradicated from one or more of the wards since the first case occurred. 
Such instances show the danger of admitting children into rooms where 
diphtheria has occurred, until a considerable period has elapsed, and 
thorough disinfection has been employed. 

When diphtheria is prevalent, indisposition on the part of a child, and 
especially febrile symptoms, or defluxion from the nostrils, should at once 
arrest attention. Although there is no complaint of soreness of the throat, 
the fauces should be carefully inspected, and if they seem too red, frequent 
gargling with one of the chlorates should be prescribed, or if the patient is 
too young to gargle he may swallow the solution, care being taken that 
the quantity swallowed does not exceed from two to four grains every hour 
or second hour. If the redness be considerable, and especially if a little 
whitish substance, whether a secretion or exudation, appear in the depres- 
sions over the tonsils, it is safer, in addition to the use of the chlorate, to 
brush the fauces with the carbolic acid mixture presently to be described, 
two or three times daily, or oftener. 

If diphtheria occur in a family, not only is prompt isolation from the 
other children imperatively required, but the fauces of these children 
should be examined daily, and if the least evidence of inflammation ap- 
pear, the treatment recommended above should be immediately employed. 
By such precautionary measures, there can be little doubt that much of 
the diphtheria which is now so fatal might be prevented. 



246 PERTUSSIS. 

Does quinine exert in anyway, or to any extent, a controlling influence 
over the diphtheritic virus ? My observations do not enable me to give a 
positive answer. I can, however, recall to mind a few instances in which 
children, who had been exposed to diphtheria from its presence in the 
family, took quinine in moderate doses each day, as a preventive, and 
although the disease appeared in them after a few days, its type was mild, 
while I recollect no instance in which the malady occurring under such 
circumstances was severe. I, therefore, think favorably of the use of 
quinine as a preventive in children who are so exposed to the diphtheritic 
virus that there is a strong probability that they will contract the malady, 
although I believe it is not so important or necessary as a strict surveil- 
lance of the state of the fauces, and the employment of topical remedies 
as directed above. 



CHAPTER 11. 

PERTUSSIS. 

Pertussis, or hooping-cough, is a contagious disea.se. It is manifested 
by inflammation of the mucous membrane of the air-passages, and a spas- 
modic cough to which this inflammation gives rise. It is due to a specific 
cause, a mnteries morhi, the exact nature of which is not known. It may 
occur both in the epidemic and sporadic form. It is probably not inocu- 
lable, although it is highly contagious, either through the breath of the 
patient, or by exhalations from his surface. With rare exceptions, it 
affects the .same individual but once. Rilliet and Barthez report a case of 
its second occurrence, and a case is also reported by Dr. West. I have 
never attended a patient in two attacks, though I can recall to mind two 
individuals, both women of intelligence, who stated that they had previous 
attacks in early life. It occasionally affects young infants, even those less 
than one month old ; and, on the other hand, adults, and rarely even old 
people ; but most cases are between the ages of one and seven years. 

Symptoms. — Pertussis consists of three stages: first, the catarrhal; 
secondly, the stage of spasmodic cough, or, for brevity, the spasmodic 
stage ; thirdly, the stage of decline. 

The first period is characterized by the symptoms of coryza and bron- 
chitis. The eyes present a moderately sufliised and injected appearance. 
There is sneezing, with defluxion from the nostrils ; and there is also more 
or less cough, dependent on bronchitic inflammation. The cough does not 
differ in character from that in the first stages of simple bronchitis, and 
there is little or no expectoration. Trousseau has known the cough to be 



SECOND PERIOD. 247 

repeated forty or fifty times per minute ; but such great frequency is rare. 
The pulse and respiration are moderately accelerated, and such other 
symptoms as commonly accompany inflammatory affections of a mild 
grade are present, namely, increased heat of surface, thirst, and impaired 
appetite. 

The duration of the first stage is various. It may, in severe cases, 
last only two or three days ; or, in mild cases, be protracted to five or 
six weeks. Its ordinary duration is from eight to fifteen days. In fifty- 
five cases observed by Dr. West, its average duration was twelve days and 
seven-tenths of a day. I have met two cases, both girls over the age of 
six years, in whom no spasmodic cough was noticed. If there was any, it 
was limited to a few paroxysms, and it might, therefore, be said that there 
was but one stage, namely, the catarrhal. They had the symptoms of the 
catarrhal stage, but instead of the occurrence of the spasmodic cough at 
the usual period, the inflammatory symptoms abated somewhat, and thei'e 
remained an occasional easy cough, like that of simple subacute bronchitis. 
This continued during a period which corresponded with the duration of 
pertussis. The diagnosis in these cases would have been doubtful, except 
for the simultaneous occurrence of pertussis, with its regular stages, in 
other children of the same families. 

Second Period. — This supervenes gradually. At first, while the 
cough ordinarily has the character presented in the first stage, it is now 
and then observed to be more severe and spasmodic. The spasmodic ele- 
ment increases gradually, so that iu the course of a week all doubt as to 
the nature of the disease, if any previously existed, is removed. 

The severity of the cough in the second stage varies considerably in 
different cases. It sometimes occurs quite abruptly, but commonly there 
is premonition of it. The patient endeavors to repress it. If a child, he 
leaves his playthings, and rest his head on his mother's lap, or takes hold 
of some firm object for support; his face has a grave or even anxious ap- 
pearance, while the pulse and respiration are somewhat accelerated. Im- 
mediately the cough commences. It consists in a succession of short and 
hurried expirations, which expel a large part of the air contained in the 
lungs, followed by a rapid and deep inspiration. There may be a single 
series of expirations, terminating in the manner mentioned ; but often 
there are two, three, or more such series embraced in a paroxysm. The 
paroxysm commonly ends in the expulsion of frothy mucus from the 
bronchial tubes, and sometimes in vomiting. The rapid passage of air 
through the glottis in the inspiration which terminates the cough, is some- 
times accompanied by a sound, which is called the hoop. During the 
cough there is temporary arrest of blood in the lungs, leading to conges- 
tion in the right cavities of the heart and throughout the systemic circula- 
tion ; therefore the face is flushed and sw'ollen, and occasionally hcemor- 
rhage occurs under the conjunctiva, or from one of the mucous surfaces. 



248 PERTUSSIS. 

The most frequent hemorrhage is epistaxis. When the cough ceases, and 
normal respiration is restored, the fulness of the vessels immediately abates; 
but often puffiness of the features is observed, due to serous infiltration of 
the subcutaneous connective tissue, and continuing for days or weeks 
during the period when the cough is most severe. 

The paroxysm lasts from a quarter to a half or even a whole minute, 
and in that time, in severe cases, there are often as many as fifteen to 
twenty series of expirations. The hoop is not as loud in infants as in chil- 
dren, and in young infants, especially those under the age of six months, 
it is often lacking, although the cough may be severe. 

At the close of the paroxysm, if there is no complication, the symptoms 
soon abate; the temperature, pulse, and respiration become normal, and 
there is no evidence of disease. The cough in the second stage is much 
more frequent in one case than another. At the height of this stage it is 
generally more severe if it occurs at long intervals than when frequent. 
During the weeks in which pertussis is most severe, there is, in the average, 
about one paroxysm of coughing in each hour. 

The cough increases in severity till the third week of the second stage, 
or the thirtieth to thirty-fifth day of the disease, after which it remains 
stationary for a certain time. It is apt to be more frequent in the night 
than daytime. Sometimes it occurs while the child is quiet ; it may even 
awaken him from sleep, but it is often also produced by mental excitement 
or by physical exertion. Anger or fright gives rise to it, and therefore the 
child is apt to cough when being examined by the physician, or when his 
wishes are not complied with. The ordinary duration of the second stage 
is from thirty to sixty days. It may, however, be considerably longer or 
shorter than this. 

The third stage, which commences at the time when the spasmodic cough 
begins to abate, is short, not continuing longer than two or three weeks. 
A protracted stage of decline indicates some complication. While the 
sputum in the second stage is mucous and frothy, that in the third stage is 
more opaque and puriform. 

In the third as in the second stage, if there is no complication, the pulse 
and respiration in the intervals of the paroxysms are nearly or quite nat- 
ural. Febrile exitement may, however, now and then occur from trifling 
causes, or, indeed, without any apparent cause. The digestion and the 
general health in uncomplicated pertussis remain unimpaired, with the 
exception of more or less emaciation, which is apt to occur in all but the 
mildest cases, in consequence of the frequent vomiting. After complete 
recovery, it is not unusual for the spasmodic cough to reappear, at times, 
for one or even two years. The cough of ordinary simple laryngitis, or 
bronchitis, assumes this character. 

Complications. — These, like the symptoms, are chiefly of a twofold 
character, namely, inflammatory and neuropathic. From the nature of 



COMPLICATIOXS. 249 

the cough iu this disease, it would naturally be supposed that the spasmodic 
aiFection, which is now designated internal convulsions, and which is char- 
acterized by spasm of certain muscles of respiration, would be a frequent 
complication. It does sometimes occur in young children, but it is not 
common. Clonic convulsions affecting the external muscles are, on the 
other hand, not infrequent. They occur chiefly in the second stage, when 
the cough is most severe, and iu infancy much more frequently than in 
childhood. They are apt to be general and severe, or, if not of this char- 
acter at first, to become such. The convulsions commence, in most in- 
stances, in or directly after the paroxysm of coughing; but they sometimes 
occur in the interval when the child is quiet. 

Rilliet and Barthez remark: "Almost all infants succumb to this com- 
plication, ordinarily in the twenty -four hours which follow the first attack; 
nevertheless, life may be prolonged during two or three days." (Article 
Coqueluche.) In my own practice, this complication of hooping-cough has 
usually terminated fatally, but I have known recovery to occur somewhat 
unexpectedly under the use of bromide of potassium. In the month of 
June, 1867, I was attending a little girl two years and four months old, 
who had reached the fifth week of pertussis, when she was seized with 
general clonic convulsions. The mother, who was requested to keep a 
record of the number of convulsions, stated that there were twenty in 
all, occurring within forty-eight hours. They affected both sides, the 
shortest lasting only three or four minutes, the longest seventy-five min- 
utes. The treatment in this case, which eventuated favorably, will be 
noticed hereafter. 

In those who die of convulsions occurring in hooping-cough, the most 
constant lesion is congestion of the cerebral veins and sinuses, often with 
transudation of serum. This congestion is due iu part to the cough which 
precedes the convulsions and in part to the convulsions themselves. At 
the autopsies which I have made of two infants, who died in hospital 
practice from hooping-cough, accompanied by convulsions, all the cerebral 
sinuses wei'e filled with clots, which were generally soft and dark ; but in 
the latei'al sinuses clots were found which were light-colored. The light 
color of a clot, either in a vein or sinus, indicates its ante-mortem forma- 
tion. 

The gravity of the convulsive attack can be ascertained by observing 
whether the patient readily recovers consciousness. Its return indicates 
that there is no serious congestion. On the other hand, great drowsiness 
remaining, or a semi-comatose state, indicates persistent congestion and, 
perhaps, even the formation of clots in the sinuses of the brain. Death 
from convulsions is usually preceded by coma. Occasionally meningeal 
apoplexy supervenes upon the congestion, and death is immediate. 

The most frecjucnt inflammatory complications are bronchitis and pneu- 
monitis. Inflammation of the larger bronchial tubes, we have seen, is a 



250 PERTUSSIS. 

common accompaniment of pertussis, but when it extends to the minuter 
tubes, or becomes so severe as to cause acceleration of respiration, it is, 
properly, a complication. Both bronchitis and pneumonitis, occurring as 
complications, are developed, with few exceptions, in the second stage. 
Bronchitis is accompanied by accelerated respiration and pulse, and in- 
creased temperature. The danger is proportionate to the amount of 
dyspnoea. 

Pneumonitis is a less common complication than bronchitis, but it 
occurs more frequently in pertussis than in any other constitutional affec- 
tion of early life, excepting measles. The congestion, which occurs and 
remains in the lung when the cough is frequent and severe, favors the 
development of pneumonia. The symptoms and physical signs which 
accompany this inflammation and serve for its diagnosis are the same as 
in the primary form of the disease, and are described elsewhere. Bron- 
chitis or pneumonia usually moderates the severity of the spasmodic 
cough, for when the inflammatory element in pertussis increases, the 
spasmodic abates. On the abatement of the inflammation, however, the 
cough usually regains its former convulsive character. The fact may be 
stated in this connection, that any complication or intercurrent disease, 
which is attended by decided febrile reaction, ordinarily renders the cough 
for the time less spasmodic. 

The occurrence of bronchitis or pneumonia is shown by the elevated 
temperature, acceleration of pulse and respiration, short and frequent 
cough. These symptoms do not cease ffs long as the inflammation con- 
tinues, whereas in uncomplicated pertussis the patient seems nearly or 
quite well between the coughs. In pneumonia the respiration is accom- 
panied by the expiratory moan, and in both bronchitis and pneumonia 
there is more or less depression of the infra-mammary region during in- 
spiration. These symptoms, in connection with the physical signs, render 
diagnosis in most instances easy. Although the general character of the 
cough is changed, a cough now and then occurs, even when the inflam- 
mation is pretty severe, sufficiently spasmodic to indicate the nature of 
the primary affection. Capillary bronchitis and pneumonia are always 
serious complications. 

It is stated by certain writers that the spasmodic cough of pertussis oc- 
casionally gives rise to emphysema and dilatation of the bronchial tubes. 
Eilliet and Barthez do not believe that these structural changes occur 
from such a cause, because the spasmodic character of the cough of per- 
tussis pertains to expiration. Later observations, however, demonstrate 
that emphysema in certain cases does result from forcible expirations 
(Niemeyer and others). Emphysema is a common lesion in young and 
feeble infants, even when there is no history of any previous severe disease 
of the respiratory organs. I have found it one of the most common 
lesions in infants of feeble constitutions who die in the Infant's Hospital 



DIAGNOSIS. 251 

and Nursery and Child's Hospital of this city. The chief cause of the 
emphysema in these eases appears to be the impaired nutrition and change 
in the molecular condition of the tissues. The same condition arises in 
severe and protracted pertussis, in which the child becomes enfeebled and 
cachectic. If severe bronchitis arises, we have still another factor in the 
production of emphysema. 

At the meeting of the New York Pathological Society, October 14th, 
1868, I exhibited emphysematous lungs removed from an infant who died 
at the age of nineteen months, and at the commencement of the fourth 
week of pertussis. Death occurred from thrombosis in the lateral sinuses 
of the cranium, resulting from the severe spasmodic cough, clonic convul- 
sions, and from feebleness of the circulation, as the infant was previously 
in a reduced state from chronic entero-colitis. At the autopsy the supe- 
rior lobes of both lungs were found exsanguine, doughy to the feel, and 
enlarged so as to rise above the level of the other lobes. The resiliency 
of the elastic tissue of these lobes was evidently greatly impaired, and 
their air-cells in a state of over-distension. The other lobes were healthy, 
except that one of them was the seat of lobular pneumonia. In the 
history of this case it did not appear that there had been any pathological 
state affecting the respiratory system joreviously to the pertussis, so that 
the commencing emphysema was referable to this disease. The forcible 
and irregular respirations which accompany the cough of pertussis appear, 
therefore, sufficient for the production of emphysema in the infant. 

I have occasionally met cases in which partial collapse of certain por- 
tions of the lungs had occurred, and the mechanism of the cough is such 
that this would be a more probable result than enlargement of either the 
tubes or air-cells. Collapse, like emphysema, may continue for weeks or 
months subsequently to pertussis, and then gradually disappear. 

Diagnosis. — During the period of invasion it is impossible to diagnos- 
ticate pertussis. Its nature can only be conjectured from a known exposure, 
or from the epidemic occurrence of the disease. In the second stage, which 
is characterized by the spasmodic cough, diagnosis is ordinarily easy, and 
often the parents are able to announce the nature of the disease when the 
physician is called. Still, a mistake is sometimes made : a spasmodic cough 
very similar to that of pertussis occasionally occurs in other maladies. 
Young infants with bronchitis frequently experience great difficulty in the 
expectoration of mucus, which collects in the air-passages and provokes a 
suffocative cough. The following facts will aid in making the diagnosis. 
Bronchitis, accompanied by a suffocative cough, is an acute disease, and the 
cough occurs at an early period, usually in the first week. It lacks the in- 
spiratory sound or the hoop, and is associated with constantly accelerated 
respiration and well-marked febrile symptoms, dependent on the inflamma- 
tion. Moreover, the cough is only occasionally suffocative, according to 
the amount of mucus in the tubes. The spasmodic cough of pertussis, on 



252 PERTUSSIS. 

the other hand, is preceded by the stage of invasion. This cough occurs in 
the second stage, when the febrile symptoms have abated ; if the disease 
is uncomplicated, it is accompanied by a hoop, and its ordinary character 
is spasmodic. Again, the suffocative cough of bronchitis rarely ends in 
vomiting, which has been seen to be so common in the cough of pertussis. 

The only other disease with which there is much likelihood of confound- 
ing pertussis is bronchial phthisis. The points of differential diagnosis are 
the following : the one epidemic, and spreading by contagion ; the other 
non-contagious, and isolated : the one embraced in three distinct stages, 
and much shorter ; the other chronic, and presenting no stages, but com- 
mencing with mild non-febrile symptoms, and progressively becoming more 
severe: in the one an absence of symptoms in the intervals of the cough, 
provided there is no complication ; in the other constant symptoms, such 
as are common in tubercular disease. The previous health, and the pres- 
ence or absence of a tubercular cachexia, should be considered in deter- 
mining the nature of the disease, and usually, in bronchial phthisis, the 
lungs are also affected, so that auscultation and percussion may furnish 
positive proof of the nature of the cough. 

Prognosis. — This is ordinarily favorable. Nearly all recover, unless 
some complication arises. In rare instances death may occur in or imme- 
diately after a paroxysm of coughing, in consequence of the rupture of 
cerebral capillaries, and the occurrence of apoplexy. Most fatal cases, 
however, are complicated with either clonic convulsions, bronchitis, pneu- 
monia, or, in the summer season, eutero-colitis, and death is due to the com- 
plication rather than the pertussis. It has been stated elsewhere that clonic 
convulsions render the prognosis unfavorable, but the case detailed above 
shows that some may recover. If the convulsion is succeeded by marked 
drowsiness, the prognosis is very unfavorable. It is probable that other 
convulsions will occur, ending in coma. Immediate recovery of conscious- 
ness shows a less dangerous form of convulsions, and one which, with proper 
treatment, may terminate favorably. 

The danger in bronchitis and pneumonia depends on the extent of the 
inflammation, the amount of dyspnoea, the age and strength of the patient. 
Capillary bronchitis and pneumonia are always serious complications. 
They have been the cause of death in a large proportion of the fatal cases 
which I have attended. Pertussis sometimes is attended with so much 
emaciation and loss of strength, in consequence of the vomiting, that in- 
tercurrent diseases, which, in favorable states of the system, would probably 
end favorably, are very apt to prove fatal. In this city epidemics of the 
diarrheal affections, so common among infants in the summer, are much 
more fatal if at the same time there is an epidemic of pertussis. In my 
practice, an infant affected at the same time with the "summer complaint" 
and hooping-cough has generally perished, unless removed to the country. 
If there is much emaciation and an hereditary tendency to tuberculosis, 



TREATMENT. 253 

the prognosis, is more unfavorable, on account of the probable occurrence 
of this disease. 

Treatment. — In the catarrhal stage the treatment should be the same 
as in idiopathic catarrh. It should consist of mild counter-irritation to the 
chest. If there is much bronchitis, with accelerated breathing, the oil-silk 
jacket may be applied. Demulcent, laxative, and gentle expectorant mix- 
tures are proper. Care should be taken to employ nothing which would 
reduce the strength, or in any way impair the general health. 

Therapeutic measures are most beneficial in the second stage, or that of 
convulsive cough. Proper treatment may prevent or control complica- 
tions, which arise chiefly in this stage, and may moderate the intensity of 
the cough. Many formulae have been recommended for the treatment of 
pertussis, most of them containing some antispasmodic. Oxide of zinc, 
musk, asafoetida, valerian, cochineal, the anaesthetics, and many other 
medicinal agents, have been employed, and there are physicians with 
whom each of these has had its season of repute. The three medicines 
which are most in favor with the profession, both in this country and 
Europe, and properly so, are hydrocyanic acid, balladouna, and bromide 
of ammonium. The employment of the last of these is comparatively re- 
cent. The others are old remedies, and their therapeutic effects are more 
fully ascertained. In my opinion, the treatment by belladonna is usually 
most successful, and this agent is more employed than any other. Some 
of the belladonna of the shops, as is true likewise of hydrocyanic acid, is 
of inferior quality, either from its mode of preparation, or the manner in 
which it has been kept, and is therefore not reliable. But if good, and 
prescribed properly, it will ordinarily render the cough milder. 

The first dose of belladonna should be smaller than will probably be re- 
quired to ameliorate the disease. The child, however, requires a larger 
proportionate dose of belladonna than an adult to produce the same effect. 
Trousseau's great experience in the treatment of children's diseases, and 
his successful practice, render his views in reference to the employment of 
this agent deserving of careful consideration. For young children he 
directed pills to be made, each containing about one-tenth of a grain of 
extract of belladonna mixed with an equal quantity of the powder of the 
leaves of belladonna. 

For children over the age of four years, the pills contained one-fifth of 
a grain of the extract and the same quantity of the powder. He directed 
that one of these pills should be taken in the morning when the stomach 
was empty, and a second on the following morning. The nurse marked 
on a card each paroxysm of coughing, so that the effect of the medicine 
could be ascertained. If the number of paroxysms was diminished, or the 
cough rendered less severe, so that there was evidently decided ameliora- 
tion, the same dose was administered each day. If, on the other hand, 
there was no improvement in the number or severity of the paroxysms, 



254 PERTUSSIS. 

t^vo pills were giveu on the followiug morning, three on the next, and so 
on till an appreciable effect was produced. Trousseau considered it im- 
portant to give at one dose whatever belladonna is administered during 
the day. The same quantity per day given in small doses, at intervals, 
he believed to be less effectual. 

The dose which he found to produce amelioration of the symptoms he 
ordered to be repeated daily during the succeeding six or eight days. 
Then, if the improvement continued, the dose was gradually diminished 
by one pill each day, back to the first dose ; but if the cough increased, 
the dose was again increased. 

Finally, when the spasmodic cough had entirely ceased, he advised the 
continuance of the medicine six or eight days longer before its complete 
suspension. 

Trousseau sometimes employed atropine in place of belladonna, since 
the medicinal properties of the plant reside in this alkaloid, and, being 
crystalline, its strength is always uniform. He gave the neutral sulphate 
of atropia in dose of about ^^4 part of a grain, dissolved in distilled water, 
to infants or young children, in the same manner as he prescribed bella- 
donna. For older children he ordered a dose proportionately larger. 
Brown-Sequard, in remarks made before the United States Medical Asso- 
ciation in May, 1866, maintained that the duration of pertussis, so far as 
the neuropathic element is concerned, might be abridged to a few days by 
doses of atropia sufficiently large to produce toxical effects. He recom- 
mends a dose which will cause, and repeated will maintain, delirium for 
three days ; after which, he states, the cough is no longer spasmodic. 

The older physicians who first advised the employment of belladonna in 
pertussis, as Schaeffer, Guersant, Goelis, and Weudt, used it with caution, 
and in small or moderate doses, apparently believing that its use involved 
considerable danger. It is now, however, considered a safe as well as 
efiicient remedy, and it is admitted that in pertussis the full benefit of the 
drug can only be obtained from doses which produce a decided impression 
on the system. If there is no amelioration of symptoms from smaller 
doses, it is proper to give it in a quantity which will cause dryness of the 
fauces and efllorescence upon the skin. 

The tincture of belladonna is most convenient for use. The doses which 
I have found to be sufficient to modify the cough, at the same time pro- 
ducing efflorescence, are as follows: To a child of two years three drops, 
to one of six to eight years ten drops, morning and evening. I always 
commence, however, with a smaller dose, and continue to administer for 
a few days the dose which is found to produce the local effects alluded to. 
In the n)ajority of cases I have noticed no decided effect till the rash was 
produced, when the symptoms improved, the cough becoming either less 
frequent or less severe. I have by means of this treatment been able to 
curtail the duration of the disease to four weeks from the beginning of the 



TREATMENT. ' 255 

catarrhal stage, even -wheu the paroxysms were unusually severe. The 
dose which proves sufficient to control the disease should be administered 
daily for a time, and then gradually diminished as the cough declines. 
Hydrocyanic acid possesses the power of controlling the spasmodic cough 
of pertussis. It is recommended by Dr. West. " I usually begin," says 
he, " with a dose of half a minim of the acid of the London Pharmacopoeia 
(that of the U. S. Ph. is the same) every four hours for a child nine months 
old; and so in proportion for older children. The specific influence of the 
remedy is, I think, both more safely and efficiently exerted by increasing 
the frequency of its administration than by adding to the dose, and I 
should therefore prefer to give half a dose every two hours, rather than 
to double the dose without increasing the frequency of its repetition. This 
remedy sometimes exerts an almost magical influence on the cough, dimin- 
ishing the frequency and severity of its paroxysms almost immediately ; 
while in other cases it seems perfectly inert." Dr. West has employed 
this remedy several hundred times, and only once has observed alarming 
symptoms from its use. The patient was two and a half years old, and 
had been ordered one minim of the dilute acid every four hours. He 
took the acid for four days without any effect being produced, either on 
his system generally, or on the cough; but at the end of that time, after 
taking the dose, he uttered a cry, became quite faint, and would have 
fallen, if not supported. 

Hydrocyanic acid, given in safe doses, does not appear to produce 
amelioration of symptoms in so large a proportion of cases as belladonna, 
and I do not know any advantages which it possesses over that agent. 
Belladonna never produces sudden alarming symptoms, like the acid. If, 
through mistake, more than the prescribed quantity is administered, it 
may cause delirium, and the characteristic effect on the mucous membrane 
of the fauces and upon the skin ; but a gradual disappearance of these 
symptoms may be confidently expected, without any injury to the patient. 
Even poisonous doses, unless excessive, are rarely fatal. If for any reason 
it is thought best to prescribe hydrocyanic acid, the following formulae 
from West may be employed : 

R. Acid, hydrocy. dil., i^lv. 
Syrupi simplici?, .5J. 
Aquae destillat., ^vij. M. 
A tortspoonful to be taken every six hours by a child nine months old. 

R. Acid, hydrocy. dibit., 'I^iv. 
Mistur. amygdiilij(3, 5J. M. 
Dose the same. 

The bromides have, within a few years, been used in the treatment of 
pertussis. They were first recammended by Dr. Gibbs, and subsequently 
by Prof. Harley, of Loudon. It is claimed for them that they produce an 



256 PERTUSSIS. 

anaesthetic effect on the mucous nu'inl)rane of the larynx. The bn^mide 
employed by the above and other physicians has commonly been that of 
ammonium, but some prescribe that of potassium, or the two in combina- 
tion. Prof Harley gives one grain of the bromide of ammonium for each 
year of the patient's age, three times daily; Dr. Gibbs gives two or three 
grains every eight hours to infants, and from four to ten grains to older 
children. Dr. Ritchie, physician to the Royal Edinburgh Hospital for 
Sick Children, says of it {Edin. 3Ied. Jour., June, 1864): "In my ex- 
perience, the remedy appears to be most successful in children whose age 
exceeds two years. . . . The quantity I have generally given has been 
from three to twelve grains a day, in divided doses, administered every 
six hours. . . . Having used the preparation in upwards of twenty cases, 
if I may be allowed to express an opinion on this head, it would be that 
the great efficacy of the drug is in uncomplicated cases ; that in those com- 
plicated with acute bronchitis, or pneumonia, the benefit is so trifling that 
I prefer other methods of treatment; for an acute congested condition of 
the air-passages appears to lessen the effect of the bromide as a laryngeal 
ausesthetic; that the more frequent the paroxysms of hooping, the more 
marked and rapid is the relief; that greater relief appears to be ex- 
perienced in those of some continuance than in recent cases ; and, lastly, 
that when chronic bronchitis is present, the bromide should not be given 
alone, but combined with squill and ipecacuanha mixture, and occasion- 
ally with an emetic." 

I have employed the bromides, though not largely, in the treatment of 
pertussis, but have not, in ordinary cases, observed that benefit which I 
had been led to expect. In recent cases, belladonna is a much more effi- 
cient remedy. I would use the bromides chiefly in advanced cases, and in 
cases, whatever the period of pertussis, in which there seems to be immi- 
nent danger of clonic convulsions. In these last cases, the bromide of 
potassium, with or without that of ammonium, is very effectual in prevent- 
ing the convulsive seizure. The hydrate of chloral has been employed 
for pertussis, in the children's class, in the outdoor dei)artment at Bellevue. 
It produces prolonged sleep, and consequently diminishes the frequency of 
the cough as long as the narcotic effect lasts, otherwise it does not seem to 
exert any influence on the symptoms or progress of the disease. 

Of late years the sulphate of quinia has been considerably employed 
for pertussis, given in doses of about two grains every three or four hours, 
to a child of five years. It has been prescribed for a considerable number 
of the children in the Catholic Foundling Asylum during an epidemic, 
which has continued many months, and affected a large proportion of the 
inmates. It did not seem to me to diminish materially the severity of the 
cough, though it was no doubt useful as a general tonic, and probably as 
a nervine, it diminished the liability to convulsions. It was in a consider- 
able number of cases administered between the doses of belladonna. In 



TEEATMENT. 257 

certain cases, it is certainly preferable to any other remedy, namely, those 
in which there is marked febrile movement, without any cerebral or intes- 
tinal complication. These cases are not infrequent, the febrile movement 
being often due chiefly to the bronchitis. 

There are many other remedies which have been vaunted in the treat- 
ment of pertussis, and which do moderate the severity of the cough. Some, 
it seems to me, have this effect by producing febrile excitement. Such is 
the use of cantharides, so as to produce active congestion of the urinary 
passages and strangury ; severe counter-irritation over the chest by tartar 
emetic, namely, Autenrieth's treatment, etc. Emetics have sometimes 
been prescribed in the first stage of pertussis, in the belief that they mode- 
rated the severity of the disease. They are more frequently employed on 
the continent than in this country. Laennec says: "Not any measure is 
more useful in the commencement of pertussis than vomiting, repeated 
every day or every two days, during one or two weeks." Some physicians 
have given for this purpose ipecacuanha, and others sulphate of zinc. 
Trousseau employed sulphate of copper. The loss of strength, however, 
which necessarily attends the employment of emetics, even the mildest, 
more than counterbalances any good effect of their use, except when there 
is considerable accumulation of mucus in the tubes, which an emetic assists 
in expelling. 

A remedy long in use, and still a favorite with many families, consists 
of half a scruple of cochineal, one scruple of carbonate of potassa, one 
drachm of sugar, and four ounces of water. The dose for a child one year 
old is a dessertspoonful three times daily; for older children the dose is 
increased in a corresponding degree. It is believed by some that the cochi- 
neal is inert, and that the beneficial effect of the above mixture is due to 
the potassa, which modifies the accompanying bronchitis. 

Alum, in doses of one to six grains, according to the age, is recommended 
by Dr. J. F. Meigs ( Treatise on Diseases of Children). Inhalation of the 
fumes arising from the purification of gas, has been recommended in Paris, 
as an effectual remedy in the declining stage of pertussis ; but, on the other 
hand, it is alleged that the benefit is due to the outdoor exercise required 
by this treatment. M. Roger employed these fumes in the wards of the 
Children's Hospital, Paris ; but apparently without benefit. Nitric acid 
has also been used internally, and applications of nitrate of silver to the 
throat; both, it is stated, with improvement in certain cases. Change of 
air is always beneficial in advanced hooping-cough. In uncomplicated 
cases the child should be carried daily into the open air; but, on account 
of the inflammatory affection of the air-passages, should never be exposed 
to cold or wet, or sudden changes of temperature. For the same reason 
the temperature of the apartment should be moderately warm and uniform. 
Great benefit, as regards the severity of the cough, often accrues, especially 

17 



258 PAROTIDITIS. 

in the advanced period of the disease, by removing the child to the country, 
or to another locality. 

Severe bronchitis, or pneumonia, which often complicates pertussis, re- 
quires the treatment which is elsewhere recommended for the secondary 
form of this inflammation, namely, the use of the oil-silk jacket, poultices, 
counter-irritation, and, internally, carbonate of ammonia or quinine, the 
latter being ordinarily preferable. As mild bronchitis is present from the 
commencement of the disease, the oil-silk jacket is useful even before the 
inflammation becomes so severe as to constitute a complication. Clonic 
convulsions, which we have seen are a common and very serious complica- 
tion, should be treated by cold to the head, a warm foot-bath, and laxa- 
tives in certain cases. The medicine which, in my opinion, is most likely 
to control the spasmodic movements, is bromide of potassium. The mode 
of administering this agent will be sufficiently explained in our remarks 
relating to the treatment of eclampsia. In the case alluded to in the pre- 
ceding pages, in which there were twenty convulsions within forty-eight 
hours, and the patient, two years and four months old, recovered, the bro- 
mide of potassium was given in combination Avith the iodide. The dose 
was about two grains of each every two or three hours. 



CHAPTER III. 

PAROTIDITIS. 

Ordinarily, parotiditis, or parotitis, or mumps, has no premonitory 
stage; but in exceptional cases languor with fever precedes the disease for 
a few hours. Mumps commences with tenderness in the parotid region, 
followed soon after by tumefaction. The swelling gradually increases ; it 
fills the depression under the ear, extends forward and upward upon the 
cheek, and downward to a greater or less extent upon the neck. It has 
been demonstrated in case of symptomatic parotiditis, and the same is 
probably true of the idiopathic disease, or mumps (Virchow), that the 
swelling is due to inflammation of the gland-ducts and consequent oedema 
of the interstitial tissue. The inflammation is specific, due to a materies 
morbi in the blood, and hence its decline after a fixed period. It reaches 
its maximum from the third to the sixth day. The most prominent point 
at this time is immediately underneath the lobule of the ear. The tumor, 
which is firm but slightly elastic, presses outward the lobule. In most 
cases the skin preserves its normal appearance over the swelling, but oc- 



NATURE DIAGNOSTS. 259 

casioually it presents a faint blush. The pressure which movements of 
the jaw produce on the gland renders mastication and even talking pain- 
ful. Febrile movement more or less intense occurs, lasting, in ordinary 
eases, not more than forty-eight hours, but occasionally it is more pro- 
tracted. Vomiting and epistaxis are sometimes present. The swelling 
having attained its maximum size, remains stationary a short time, when 
it begins to decline, and by the sixth to tenth day it has entirely subsided. 

In most cases parotiditis is double ; it commences on one side, more 
frequently the left than right, and in from one to four days the opposite 
gland is involved. In those exceptional cases in which only one parotid 
is affected, the opposite gland may be the seat of the disease at some sub- 
sequent period. It has been estimated that the proportion of unilateral 
to double mumps is as one to ten. 

The total duration of this disease is usually from eight to ten days ; in 
the mildest cases it may not be more than five days. The submaxillary 
glands are often involved in connection with the parotids, and sometimes 
also the sublingual, although, from their small size and concealed position, 
their tumefaction escapes notice. Rarely the tonsils are also tumefied. 
Sometimes free perspiration occurs at the commencement of convalescence. 

The swelling of the parotids sometimes abates suddenly, and in the 
male the testicle, epididymis, and tunica vaginalis become inflamed ; 
while in the female the mammary glands, ovaries, or the labia majora, 
are the seat of the so-called metastasis. Occasionally these inflammations, 
which are less frequent in young children than those near the age of 
puberty, when the sexual organs are becoming more developed, occur 
without subsidence of the parotid swelling. They cause considerable 
increase in the fever and constitutional disturbance, but with proper 
treatment decline in six to eight days, pursuing the same course as the 
parotid inflammation. 

Nature. — Parotiditis is contagious. It is rare in infancy and after 
the middle period of life, occurring chiefly in childhood, youth, and early 
manhood. An incubative period of about twelve days was ascertained by 
me in cases occurring in the Protestant Episcopal Orphan Asylum of this 
city. The observations of others give a similar result. Parotiditis is a 
blood disease, having the local manifestation described above, and which 
is our only means of diagnosis. 

Diagnosis. — If the physician has seen but few cases of mumps there is 
danger that he may mistake the swelling for an inflamed cervical gland, 
or vice versa, but an inflamed cervical gland presents to the finger a hard- 
ness almost like that of cartilage, and it is circumscribed or round, and 
does not invest the ear. These characteristics contrast with the elasticity, 
seat, and shape of the parotid swelling, which extends forward on the 
cheek and surrounds and elevates the lobule of the ear. Tumefaction 



260 PAROTIDITIS. 

resulting from diphtheritic or any other form of faucial inflammation, or 
from periostitis affecting the root of the posterior molar, may be detected 
by examining the fauces and interior of the mouth. 

Treatment. — This is very simple. Oakum or carded wool may be 
bound over the swelling, and the surface occasionally rubbed with sweet 
oil. Mild laxative and diaphoretic drinks, such as bitartrate of potash 
or lemonade, are useful. If metastasis occur, the new local affection 
should receive chief attention. It should be treated in the same manner 
as if it occurred independently of the mumps. The employment of irri- 
tants over the parotid in order to cause a return of the inflammation 
from the sexual organ to this gland, does not have the effect desired, and 
is injurious. 



SECTION lY. 

OTHEK GENERAL DISEASES. 



CHAPTEK I. 

INTEKMITTENT FEVER. 

This is a constitutional malady produced by a miasm which emanates 
from the soil. I have notes of 36 cases of this disease occurring under the age 
of 3 J years. Several of the cases were treated in private practice, and the 
rest in the institutions with which I have been connected. In children above 
the age of Si years intermittent fever diifers but little from that of the 
adult, while in those under this age it presents certain peculiarities. Of the 
36 cases which I have observed, 19 had the quotidian form, 10 the tertian, 
2 the tertian becoming afterwards quotidian, 1 the quotidian becoming 
afterwards tertian, while in the remaining 4 cases the form of the disease 
is not stated. In quotidian ague the malaria has been supposed to act 
more powerfully on the system, or the system is more susceptible to its in- 
fluence than in the tertian form, and hence the fact that the quotidian is 
the prevailing type of ague in tropical regions, where vegetation is luxuri- 
ant, marshes extensive, and the heat intense. According to this theory, the 
feeble resisting power in the system of the infant explains the fact that it 
has quotidian more frequently than tertian intermittent, although the lat- 
ter is much more common in the adult in this climate. 

Facts demonstrate that infants sometimes receive intermittent fever from 
their mothers. If mothers during gestation have malarious cachexia, their 
infants, whether born at full time, or, as often happens, prematurely, are 
apt to be small, thin, and feeble, and occasionally they have soon after 
birth distinct paroxysms of the ague. Dr. Stokes related the case of a 
pregnant woman with ague, who believed that she noticed periodical tremors 
of her foetus, but I suspect that she was mistaken, at least as regards the 
cause, for the paroxysm of intermittent in young chiklren is not ordinarily 
accompanied by a chill. 

The youngest infant in my practice who apparently derived the ague 



262 IXTERMITTEXT FEVER. 

from its mother, and probably through the foetal circulation, had the fol- 
lowing history : Its mother had occasional attacks of tertian intermittent 
during the two years preceding her confinement, and her baby when one 
week old was observed to have the same disease, occurring also each 
second day, the coldness and blueuess in the first stage of the paroxysm 
lasting from half an hour to one hour. 

It is not fully ascertained whether a nursing infant may contract inter- 
mittent fever by lactation, but if it is admitted that it is sometimes com- 
municated to the foetus through the maternal circulation, it does not seem 
improbable that the specific principle occasionally enters the milk as well 
as other secretions. I have frequently remarked the presence of the disease 
in nursing infants whose mothers were affected, and in one instance an 
infant at the breast, wiiose mother had the ague, having contracted it in a 
suburban village, but was since living in a non-malarious part of the city, 
presented evident symptoms of the disease. Similar observations by 
Frank, Burdel, and others, do not indeed fully prove the communicability 
of intermittent fever by lactation, but render it highly probable. 

The period of incubation in the infant varies greatly, as in the adult. 
When the malaria is concentrated and unusually active, or the condition 
of system is favorable for its reception, the disease may commence soon 
after exposure. Thus, in tropical regions, travellers exposed for a single 
night, have been known to sicken within twenty-four hours ; but in our 
cooler latitude, a longer incubative period is the rule. In the infant, how- 
ever, in our climate, intermittent fever often begins in a very short time 
after exposure, though there may be an incubative period of some weeks, 
The following have been my observations relating to this point : A. M., 
female, 8 months old, remained two days on Long Island, in October, 
1870, and three days after her return to the city, a quotidian commenced. 
P. S., male, 11 months old, remained three days on Long Island, and a 
quotidian commenced four days after his return. K., 9 months old, re- 
mained on Staten Island one week, and eleven days after his return, a 
tertian commenced. G. K., aged 3 years, remained a day and night on 
Staten Island in 1870; three weeks afterwards intermittent fever com- 
menced, preceded by a week of languor. A. U., female, aged 2 years and 
2 months, had the first paroxysm of a tertian, two and a half weeks after 
returning from a visit of one week in Hoboken. As there was no malaria 
in the portions of the city where these infants resided, the incubative 
periods are nearly ascertained. 

Whatever may be the nature of the malarial poison, whether a vege- 
table cell, as Prof. Salisbury believes, or something else, it often clings 
tenaciously to the system, and is probably reproduced in it, even under 
circumstances favorable for its elimination. Thus, at one of my cliniques 
at Bellevue Hospital Medical College in 1871, a child, 10 years old, was 



SYMPTOMS. 263 

presented, who had had every year for seven years attacks of intermittent 
fever. The disease was contracted at the age of three years in Harlem, 
and the subsequent residence of the family had been in a part of the city 
where there was no malaria. 

Symptoms. — In infancy, and especially prior to the age of eighteen 
months, the symptoms differ in certain respects from those which charac- 
terize the malady in the adult, and are universally known. In childhood 
the symptoms are similar to those in the adult, and need not, therefore, be 
described in this connection. 

In the infant the type as we have seen is quotidian, with now and then 
a tertian. Advancing beyond the age of eighteen months, we meet more 
and more cases of the tertian type, and in childhood it is the common 
form. I have known the quotidian in the infant, when cured, to reappear 
a few weeks after as a tertian; but ordinarily it remains quotidian, unless 
the patient has reached the age at which the tertian type predominates. 

The paroxysm in the young infant presents three stages, as in the adult, 
but while the second, or febrile, is well marked, the first and third are 
much less pronounced. The patient does not shake (exceptionally, one 
does even within the first year) in the first stage, but a slight tremor may 
or may not be observed. The countenance presents a sunken appearance ; 
the lips and fingers are livid, while portions of the surface not livid are 
pallid, with the gooseflesh appearance, which is, however, less marked 
than in children of a more advanced age. The blood leaves the sur- 
face, which consequently shrinks, while it accumulates in the veins and 
internal organs ; the pulse is feeble, and readily compressed ; the surface 
grows cool from the diminished supply of blood, but the breath is warm, 
and the internal temperature, so far from being reduced, is elevated two or 
three degrees. The parents may be alarmed at the sudden sinking of the 
vital powers, and seek medical advice, but in other instances the first stage 
is so slight that it passes unperceived till they have been taught to watch 
for it, and the second stage first attracts attention. 

In the second or febrile stage, which immediately succeeds, the pulse 
becomes full and rapid, 120 to 130 or 140 beats per minute, and the ex- 
ternal as Avell as internal temperature is elevated as in few other diseases 
(104°-108^). The face is flushed, surface dry, and head painful, as 
evinced by the features. This stage lasts about two or three to six or eight 
hours. The third stage, or that of perspiration, succeeds, which terminates 
the suffering of the patient till the following paroxysm. In infancy the 
perspiration is not abundant, and in the first half of this period is nearly 
absent. In the interval of the paroxysms the patient appears well, except 
a degree of languor. 

In twenty-four of the cases of infantile intermittent which I have treated, 
my notes describe the character of the paroxysms. In sixteen of these 



264 INTERMITTENT FEVER. 

there was no chill or trembliug in the first stage, but blueness and coolness 
of the extremities and features, and sudden prostration. This stage lasted 
from ten minutes to one hour. In the eight remaining cases the infants 
were observed to tremble or shake as in adult cases. The perspiration of 
the third stage was in nearly all cases slight and of short duration, and in 
some was not observed. 

During the cold stage, passive congestion of the internal organs occurs 
to a greater or less extent, but the circulation is equalized during the re- 
action of the second stage. The spleen, whose capsule is distensible, soon 
enlarges in many patients, in consequence of the frequent and great con- 
gestions, constituting the " ague cake." This enlargement is more common 
in children than adults. Since my attention has been particularly directed 
to this subject, I have been able to feel the enlarged spleen, by examina- 
tion through the abdominal walls, in probably one-third of the cases under 
the age often years. This organ returns to the normal size after the ague 
is cured. From the intimate relation of the spleen to the composition of 
the blood, it is evident that the character of this fluid must be affected if 
intermittent fever be protracted. The blood becomes more and more im- 
poverished, and a state of decided hydrseraia supervenes. A few weeks' 
continuance of the ague suffices to produce decided pallor of the features, 
and surface generally, and as all watery blood is prone to transudation, 
such patients not infrequently present more or less oedema of the face, 
ankles, and other parts. Sometimes, also, especially under unfavorable 
hygienic circumstances, purpuric spots (purpura hsemorrhagica) appear 
under the skin, affording additional proof of the change which the blood 
has undergone. 

In long-continued cases of malarial disease in the adult waxy degenera- 
tion of organs is apt to occur, as well as melansemia. Pigment cells, flakes 
and particles appear in the blood, the coats of the minute arteries, and 
in various organs, as the spleen, liver, etc. In the child these results are 
more rare. 

Intermittent fever in children, if proper remedial measures are employed 
at an early period, is ordinarily not dangerous, and is quite amenable to 
treatment ; but that comparatively infrequent and fatal form of it, des- 
ignated the pernicious, occurs more frequently in children than adults. 
In New York City, where the type of malarial diseases is mild, I have 
never met a case of pernicious intermittent in the adult, but I can recall 
to mind such cases in children, two of them fatal. This form of the fever 
occurs in a smaller proportionate number of cases in infancy than in child- 
hood, probably because the cold stage is less pronounced. In the pernicious 
ague, the system is overpowered — it does not react in a degree commen- 
surate with the intensity of the disease. The patient enters the cold stage, 
becomes stupid, and, if not relieved by prompt and efiicient measures, 



TREATMENT. 265 

into a fatal coma. A type of the disease, therefore, which would 
not be pernicious in a robust individual, may be such in one of a broken- 
down constitution and feeble reactive power. In most cases occurring in 
children the coma is preceded by eclampsia, which is apt to be general and 
protracted. 

Eclampsia increases the passive congestion of the cerebro-spinal axis 
already present in this stage, and if not speedily relieved may end in 
transudation of serum over the surface of the brain, and perhaps meningeal 
apoplexy, causing fatal coma. This has occurred twice in my practice. 

Sometimes in young children the diagnosis of intermittent fever is 
doubtful, either because the disease has not continued sufficiently long, 
or there has not been the characteristic paroxysm. The patient may be 
feverish, and fretful, with anorexia, and evidences of headache, but with- 
out the usual distinctive symptoms. I have sometimes in such cases been 
able to establish the diagnosis by detecting enlargement of the spleen. In 
examining for the "ague cake," the child must lie quietly on its back, and 
the fingers, placed midway between the epigastrium and uuibilicus, be car- 
ried gently but with firm pressure outward in the direction of the spleen, 
when the anterior edge of this organ will be felt, if it be enlarged. It is 
impossible to make the examination when the child cries, on account of 
the contraction of the abdominal muscles. 

Treatment. — It is evident that no time should be lost in applying ap- 
propriate remedies in a case of infantile ague ; for although the first 
paroxysm may be mild, the next may be more severe, and attended by 
danger. Moreover, the sooner the disease is cured the less liable it seems 
to be to return. Therefore we prescribe at once the sulphate of quinia or 
ciuchonia, one and a half grains of the latter producing the effect of about 
one grain of the former. Our experience in the children's class in the 
Outdoor Department has been chiefly with the sulphate of cinchonia, on 
account of its cheapness, and there has yet been no case of ague which it 
has failed to control. A recent writer has published statistics showing his 
success in curing intermittent fever by this agent, but nothing in thera- 
peutics is more easy than to cure this disease in our climate by either of 
the sulphates mentioned. The chief difficulty consists in preventing a re- 
turn. To an infant of two yeai's I prescribe one grain of sulphate of quinia, 
or the equivalent of sulphate of cinchonia, three times daily, till all symp- 
toms of the ague have disappeared ; then twice a day during the subsequent 
week, and afterwards once a day for some days ; and finally twice or thrice 
a week. It is only by the protracted use of the drug in occasional doses 
that the return of the intermittent can be prevented. 

It is important in administering these sulphates to infants to employ a 
vehicle which will, so far as possible, disguise the bitterness. The vehicle 
which I prefer for their administration is the syrup of raspberry, which. 



266 REMITTENT FEVER. 

though not officinal, is easily obtained. The follo^viug formula is for a 
child of three years : 

R. Qui. sulphat., gr. xij. 

Acid, sulphur, dilut., gtt. xviij. 
Syr. rubi. idaei., Jjss. Misce. 

One teaspoonful three times daily. The first dose should be adminis- 
tered immediately after the fever abates. In this climate two or three 
days suffice to cure the disease, after which by daily but gradually di- 
minished use of the medicine in the manner stated above, the return of the 
malady is prevented. 

If any difficulty is experienced in administering the medicine on account 
of its bitterness, the dragees may be employed, if the child is old enough 
to swallow them, or the tanuate of quinine. The tannate may be ad- 
ministered by substituting tannic acid for the sulphuric. One grain of 
tannic acid is sufficient to form a tannate with four grains of the sulphate 
of quinia. The tannate, however, is not as reliable as the sulphate, and 
it is necessary to administer it in a somewhat larger dose. Protracted 
cases attended by anaemia require the use of iron in addition to the remedy 
which is designed to control the disease. 



CHAPTER 11. 

EEMITTENT FEVER. 

If a physician were to consult the standard treatises on diseases of 
children, in order to ascertain the nature of remittent fever, he would 
rise from the perusal with no clear idea of it. One tells us that the re- 
mittent fever of children is identical with typhoid fever of adults; another, 
that it is a gastro-intestinal inflammation ; and, finally, Hillier believes 
that there is jiroperly no such disease, and that the term should be dropped 
from the nosology of children. There is, however, a remittent fever of 
children as well as adults, and much of the confusion which exists in 
reference to it arises from the fact that writers have not kept in view what 
constitutes a fever. 

Febrile action which has a local cause is not an essential fever, and 
should not be described as such. It happens that in children a sympto- 
matic remittent fever arises from a variety of local causes, as dentition, 
intestinal worms, subacute gastro-intestinal inflammation, etc. But all 
such cases should be excluded from our consideration of remittent fever, 
as clearly as we distinguish the continued fever of pneumonia or bron- 
chitis from that of typhus or typhoid. 



SYMPTOMS DIAGNOSIS. 267 

There is an essential remittent fever of children due to malaria. The 
same conditions which produce intermittent fever do, in a certain propor- 
tion of cases, produce a fever which does not intermit, but continues with 
more or less pronounced exacerbations a certain number of days, when it 
ceases or becomes intermittent. Those who practice in malarious localities 
notice a larger pi'oportion of cases of remittent fever among children 
than adults, because their constitutions are less able to resist the malarial 
poison, so that an exposure which in an adult would produce milder dis- 
ease, namely, a tertian ague, is apt to cause a quotidian or remittent in 
the child. In young and feeble infants the proportionate number who 
have remittent fever is large. Cases, too, are not infrequent in localities 
not malarious, of a remittent fever, occurring more frequently in the 
spring and autumn than in other seasons. Some of these cases are per- 
haps a mild type of typhus, but in most instances the conditions do not 
appear to be present which ordinarily give rise to typhus, and they do not 
occur in connection with cases of typhus in adults. The cause, though 
obscure, is apparently atmospheric. 

The SYMPTOMS of remittent fever vary in different cases. The exacer- 
bations and remissions are more pronounced in some than others. Even 
in those cases in which the fever is due to paludal emanations, and occur* 
in connection with cases of the intermittent, the febrile movement may be 
almost uniform, slight exacerbations occurring in the latter part of the 
day. In other cases the exacerbations and remissions are pronounced, the 
febrile excitement abating in a perspiration. Occasionally the fever is 
higher on each second day. Cephalalgia is common, and in severe cases 
delirium and stupor are not infrequent. There may be distinct remissions 
in the beginning, and afterwards, for a few days, the fever be pretty uni- 
form, when it again remits or ceases. The tongue is covered with a light 
fur. Thirst, loss of appetite, a tendency to constipation, scanty and high- 
colored urine, containing perhaps urates, and a cough due to mild bron- 
chitis, are common symptoms. 

When remittent fever is due to marsh emanations, the same anatomical 
characters are doubtless present as in the adult, namely, blood containing 
more or less pigmentary matter, enlargement of the spleen, bronzing of 
the spleen, and, in severe cases, of the liver, and sometimes of the brain. 

The DiAG>'OSis is not always easy. On the one hand, local diseases 
with symptomatic remittent fever are to be excluded, and, on the other, 
typhus and typhoid. The discrimination of it from typhus and typhoid 
fevers is practically of little moment, but it is a matter of vital importance 
to make a differential diagnosis between it and the local diseases. I have 
known one of the acutest diagnosticians and most eminent physicians of 
New York mistake incipient meningitis for it, a mistake indeed not un- 
common. The points involved in a differential diagnosis will be consid- 
ered in our descriptions of the local diseases. 



268 TYPHOID FEVER. 

Treatment. — If we have ascertaiued by a careful examination that 
the fever is remittent, and not symptomatic but essential, there is one 
remedy which is required in nearly all cases, namely, quinia, or its equiv- 
alent, cinchonia. Mild febrifuge medicines, with light diet, may be first 
employed in sthenic cases, in which the pulse is full and strong, and the 
quinia given when the fever has somewhat abated. The diet should be 
bland, but nutritious, and the bowels be kept regularly open by citrate of 
magnesia or other mild aperient. Bromide of potassium or hydrate of 
chloral may be occasionally employed as recommended in the treatment 
of typhoid fever, to produce quietude or sleep, in cases attended by de- 
lirium or insomnia. A warm mustard foot-bath and cool applications to 
the head are useful in such cases. 



CHAPTER III. 

TYPHOID FEYEK. 

Typhus and typhoid fevers occur in children, but the former is mild 
and infrequent, rarely occurring except when adults of the same household 
are affected. It requires little treatment, except good nursing. Typhoid 
fever, on the other hand, is not infrequent in children, and, as it presents 
certain peculiarities prior to the age of puberty, it is proper to describe it 
in this connection. This disease is much less frequent in infancy than in 
childhood, and in the first half of infancy is believed to be rare. Still, 
there can be no doubt that many cases in the first years of life are not 
diagnosticated, being mistaken for subacute and protracted entero-colitis. 
It may, therefore, be more common in the infant than is commonly sup- 
posed. Its period of greatest frequency in children is between the ages 
of six and twelve years. 

Causes. — It is now generally admitted that typhoid fever is mildly 
contagious, and that its specific principle abounds largely in the dejections 
and excretions of the patient. It is uncertain whether it is communicable 
by the breath of the patient, or exhalations from his surface. If it is, it is 
slightly so, while numerous observations demonstrate its communicability 
through the use of night-stools or privies which contain the evacuations. 

There is little doubt also that typhoid fever orignates de novo, caused 
by the miasm produced by decaying animal or vegetable matter. Numer- 
ous cases have been observed in which it originated from defective sewer- 
age, or decaying vegetables in cellars, in localities in which no case had 
previously been observed. The germs of the disease may not only be 
received into the system by inspiration, but also through the stomach, for 



ANATOMICAL CHARACTERS. 269 

the use of well-water which contains the drainage of sewers has repeatedly 
been known to cause it. Boys are more frequently attacked than girls, 
according to some statistics in the proportion of three to one. Deteriora- 
tion of the health from general causes increases the liability to be attacked. 
On the other hand, those having tuberculosis, carcinoma, heart disease, 
and probably certain other visceral lesions, are more apt to escape than 
those in health. 

Anatomical Characters. — As typhoid fever is a constitutional dis- 
ease, we would expect to find early and important changes in the blood. 
No alteration, however, has been discovered in this fluid peculiar to typhoid 
fever. The amount of fibrin is diminished as in most of the essential fevers, 
and its coagulation is feeble, forming, when the blood stands, soft, small 
and dark clots. When the fever has continued for some time, a state of 
ansemia more or less decided supervenes, in which the amount of albumen 
and blood-corpuscles is diminished. Although there are often decided 
symptoms referable to the nei'vous system, no constant changes have been 
discovered in the brain or spinal cord. The changes observed in them 
when death has occurred in the course of typhoid fever have been for the 
most part due to other causes. It is different with the respiratory system. 
After the first week of typhoid fever bronchitis is almost as constant as 
inflammation of the fauces in scarlet fever, and accordingly we find in 
fatal cases redness and thickening of the bi'onchial mucous membrane, 
which is covered with a viscid and ordinarily scanty secretion. Hypo- 
static congestion of the lungs, with more or less oedema, and in severe and 
enfeebled cases hypostatic pneumonia, are not uncommon. In the bron- 
chitis and state of feebleness w^e have the causes of pulmonary collapse, 
and this lesion is not infrequent over limited portions of the lungs, especi- 
ally if the bronchitis affects the smaller tubes. 

The lesions occurring in the digestive system are important. The mu- 
cous membrane of the small intestine is more or less injected, and at an 
early period, even by the second or third day, the patches of Peyer, soli- 
tary glands, and at the same time the mesenteric, begin to enlarge. It has 
been stated by high authorities that the enlargement is due to infiltration 
with a peculiar substance, which has been termed the typhous material. 
I have made microscopic examination of these glands in typhoid fever of 
the adult, and have found a notable increase of the small round granular 
cells of which these glands are composed. I do not, therefore, doubt that 
the enlargement is due mainly to hyperplasia of the cellular elements of 
the glands, though there is probably infiltration to a certain extent of 
inflammatory products between the cells. The mucous membrane over the 
glands undergoes inflammatory thickening and softening. In the adult, 
sloughing of this membrane is frequent, with the disintegration of the 
glands and their elimination into the intestines, producing ulcers, small 
and circular, corresponding with the site of the solitary glands, large and 



270 TYPHOID FEVER. 

oval or irregular, corresponding with the site of the agminate. Disinte- 
gration of these glands and the formation of ulcers are less frequent in 
children than in adults. In the adult, who recovers, the mesenteric glands, 
and those of the solitary and agminate which are not destroyed, return to 
their normal state by fatty degeneration, liquefaction and absorption of the 
redundant cells. In the child this is the common result, instead of slough- 
ing and disintegration, as regards both the solitary and agminate glands, 
and uniform result as regards the mesenteric, and I may add bronchial 
glands, which are also in a state of hyperplasia. The absence of ulceration 
or its slight extent affords explanation of the fact that intestinal perfora- 
tion is very rare in children. 

The spleen gradually enlarges, often to twice the normal size, has a dark 
red color, and is softened. Enlargement of the spleen possesses great diag- 
nostic value in those cases in which the diagnosis is obscure. For w^hile 
very similar intestinal lesions may occur in chronic entero-colitis, the co- 
existence of these lesions wuth the splenic enlargement and softening shows 
the constitutional nature of the affection. 

In cases which are severe, and which present a decidedly adynamic 
type, the muscles become soft and flabby, the action of the heart is feeble, 
and more or less passive congestion of the viscera results. In such cases 
congestion of the kidneys and albuminuria are not infrequent. 

Symptoms. — Typhoid fever has a prodromic stage of a few days, some- 
times of a week or more, in which the child appears languid, indisposed to 
play, and has little appetite, but complains of no pain unless occasional 
slight headache, and has no symptom which would lead the friends or even 
physicians to suspect the grave nature of the disease which impended. By 
and by a slight fever occurs. 

The febrile movement, which gradually becomes more pronounced, re- 
mits, but does not cease in the morning, and has evening exacerbations. 
After the first week of fever the remissions are less marked, but the fever 
is not uniform at any period in its course. Hence some of our ablest writers 
on diseases of children continue to designate typhoid fever of children re- 
mittent fever, fully aware of its identity with typhoid fever of the adult. 
As the case advances, the appetite fails, all solid food being refused, and 
liquid food being taken more from thirst than hunger. The tongue in the 
first week is covered with a light moist fur, and in some patients through- 
out the course of the disease, but in others having a graver type of the fever 
the tongue after the first week is dry and brown. During the prodromic 
period, and in the first week, the bowels act regularly, or are slightly re- 
laxed, and they are readily affected by purgative medicines. After the 
first week there is in most children a tendency to diarrhoea, which requires 
now and then the use of astringents, the stools being watery and brown, or 
dark yellow. The abdominal walls are seldom retracted, but prominent, 
especially after the first week, in consequence of meteorism which is present 



SYMPTOMS. 271 

in children as well as adults. Sometimes there is apparent tenderness, when 
pressure is made over the right iliac region, but this must not be confounded 
with hypersesthesia, which is common in the commencement of febrile dis- 
eases in children, and which is observed especially upon the abdomen, chest, 
and inner part of the thighs. 

The respiration in the first week is slightly accelerated, as it is in all 
febrile diseases. In the second week, and subsequently when bronchitis is 
developed, the respiration is ordinarily more accelei-ated, though not in a 
marked degree, unless in those exceptional instances in which there is an 
abundant collection of mucus in the smaller bronchial tubes. A cough is 
always pi'esent, dependent on the bronchitis, and varying in character ac- 
cording to the degree and stage of the inflammation. In the first days of 
the fever it is infrequent, and hacking ; at a later stage it is more frequent, 
and not so dry, though in cases of ordinary severity the amount of expec- 
toration is inconsiderable. Hypostatic congestion, oedema, hypostatic pneu- 
monia, splenization, or thickening of the alveolar walls, and collapse, which 
may and some of which not infrequently do occur in the advanced disease, 
increase more or less the frequency of the respimtion and the cough, and 
modify the physical signs. 

The pulse in the first week, in ordinary cases, is from 100 to 110 or 115. 
It gradually becomes more accelerated, numbering in the second week 120 
or more ; in grave cases even 160. The more frequent the pulse, the greater 
the danger and more unfavorable the prognosis. During the exacerbations 
the number of pulsations per minute is 15 or 20 more than in the remis- 
sions. The change in temperature corresponds with that of the pulse, being 
from 1° to 2° higher in the exacerbation than remission. The extremes of 
temperature in cases of ordinary severity are about 101° and 104°. A 
temperature above 105° shows a grave, pi'obably, a malignant, type of the 
disease, or else a serious complication. 

There is great variation as regards the symptoms referable to the nervous 
system. Headache is common in the prodromic and initial stages, after 
which it ceases. A few are delirious even from an early period, screaming 
loudly, or muttering incoherently, but the majority are quiet, having, in- 
deed, a degree of mental dulness, but being able to appreciate questions 
when aroused, and answering correctly. Subsultus tendinum and car- 
phologia, which some exhibit, show that there is profound disturbance of 
the nervous system. Epistaxis occurs occasionally in the first week as in 
the adult, but is not abundant. 

The rose-colored eruption appears in children as well as adults between 
the sixth and twelfth days, but is more frequently absent in the former 
than latter; sometimes the number of spots is less than half a dozen. 
Sudamina are common in the second and third weeks, and perspirations 
may occur at any time in the course of the fever, but without ameliora- 
tion of symptoms. More or less deafness is common, being in most in- 



272 TYPHOID FEVER. 

stances a purely nervous symptom, without, therefore, any structural 
change in the ear, but it is possible, as has been suggested by certain 
writers, that it sometimes results from inflammatory thickening of the 
Eustachian tube or external meatus, or to a weakened and flabby state of 
the muscles of the ear. 

The duration of typhoid fever is not uniform ; while mild cases may end 
iu two weeks, those of a severer type continue three or even four. The 
patient becomes progressively more emaciated and feeble. In protracted 
and severe cases his condition seems very unpromising to one not familiar 
with the clinical history of the fever. Pale, emaciated, and feeble, prob- 
ably passing his evacuations in bed, taking little notice of objects around 
him, he presents, at the close of the third week, an appearance of helpless- 
ness, notwithstanding the best of nursing, and the constant employment of 
sustaining measures, which is truly discouraging. 

Complications. — The chief complications of typhoid fever are broncho- 
pneumonia, already sufliciently described, enteritis, intestinal haemorrhage, 
peritonitis, otitis, parotiditis, and muguet. In one instance I lost a patient 
about ten years old, in whom the fever had nearly terminated, by the 
sudden accession of croup. There is, as we have seen, in ordinary cases, 
more or less inflammation of the mucous membrane of the air-passages, and 
of the intestines especially in the vicinity of the patches of Peyer. It is 
easy to understand how, under circumstances which may arise in the fever 
favorable to the development of mucous inflammations, the bronchitis and 
enteritis may so increase as to constitute complications. They are the most 
frequent of the serious complications. 

Intestinal haemorrhage is an occasional accident. Hillier met four cases 
in thirty of the fever. It indicates the presence of ulcers upon the sur- 
face of the intestines. The younger the child, the less the liability to it. 
Some, in whom it has occurred, recover, but others die. Otitis, com- 
mencing with pain, and producing a discharge which may continue for 
weeks, is not rare, though less frequent than in scarlet fever. The otitis 
is commonly external, but it may, in scrofulous subjects, extend to the 
middle ear. 

Intestinal perforation is more rare in children than in adults, as might 
be inferred from the statement already made, that intestinal ulceration is 
less frequent and extensive in them. Statistics show that perforation oc- 
curs only once in 232 cases. Therefore, as perforation is the common 
cause of peritonitis in this disease, this inflammation is a rare complica- 
tion. Peritonitis may, however, occur in typhoid fever without perfora- 
tion. In one such case (an adult) iu the fever wards attached to Charity 
Hospital, local peritonitis with fibrinous exudation occurred opposite two 
ulcerated patches of Peyer, the ulcers extending nearly to the peritoneum, 
but not perforating. The lesions observed in this case throw light on 



DIAGNOSIS. 273 

those cases of peritonitis complicating typhoid fever which recover, the 
cause of which has received a different explanation. 

In advanced and greatly debilitated cases, thrush sometimes appears in 
the interior of the mouth, and upon the fauces. It is always an unfavor- 
able prognostic symptom in children suffering from chronic or proti'acted 
disease. Parotiditis is also a rare complication. 

Diagnosis. — This is more difficult in children than in adults, and the 
younger the child the greater the difficulty. In infants protracted entero- 
colitis, with febrile action and dry furred tongue, cannot in certain cases be 
positively diagnosticated from typhoid fever by the symptoms and clinical 
history. Typhoid fever is believed, however, to be rare at this age. When, 
however, as now and then happens, a young child presents the symptoms 
characteristic of protracted subacute entero-colitis, or typhoid fever, and 
older members of the household have the fever, it is highly probable that 
the case is one of the latter disease, and it should be treated accordingly. 

Even in older children typhoid fever is apt to be mistaken for simple 
subacute enteritis, or eutero-colitis, or vice versa. The following facts aid 
in the differential diagnosis. In typhoid fever there is total loss of ap- 
petite, while in the subacute intestinal inflammation food is not entirely 
refused. Diarrhoea commences early in the inflammation, while in the 
fever it is not ordinarily till after the lapse of a few days. The tender- 
ness of the fever is either not appreciable, or it is located in the right iliac 
region ; in the other disease it is general over the abdomen, or located ia 
the umbilical region. In typhoid fever there is bronchitis with a cough 
which is absent in the inflammation. In typhoid fever there are certain 
other symptoms, more or fewer of which are present in most cases, and 
which do not occur in the intestinal diseases, except as a coincidence; 
for example, headache, epistaxis, stupor, delirium, and perhaps the rose- 
colored spots. 

Typhoid fever may be mistaken for meningitis, during the first week, 
but in meningitis there is more constipation, irritability of stomach, and 
less elevation of temperature. Moreover, in meningitis, at a comparatively 
early stage, we are able to detect patches of congestion of the features 
coming and disajjpearing suddenly ; and slight inequality of the pupils, or 
their oscillation when the light is uniform; signs which are lacking in 
typhoid fever. In a doubtful case the ophthalmoscope might be employed, 
which in meningitis discloses congestion of the vessels of the retina, oedema, 
etc., anatomical changes which do not pertain to typhoid fever. 

The differential diagnosis of typhoid fever and acute tuberculosis may 
be made by attention to the following points. In tuberculosis there is 
cough, with some acceleration of respiration from the first, without epis- 
taxis, stupor, or other nervous symptoms, and without the abdominal 
symptoms which are so prominent in the fever. 

Duration. — The duration of typhoid fever varies from two to about 

18 



274 TYPHOID FEVER. 

four weeks, but complications which may arise, may protract the febrile 
movement. Eecovery from a severe and protracted attack is slow, several 
weeks or even months elapsing before complete restoration to health. A 
tendency to diarrhoea often continues several weeks after the fever proper 
ceases, necessitating a rigid oversight of the diet, and the occasional em- 
ployment of astringents. 

Prognosis. — A much larger percentage of children recover than of 
adults. Although there is great emaciation with loss of strength, recovery 
may be confidently predicted, provided that no serious complication 
occurs. In fatal cases which I have met, the unfavorable result occurred 
as a rule from the complications, rather than directly from the malady. 
The condition in which severe typhoid fever leaves a patient is favorable 
to the development of tubercles, and now and then they occur, disappoint- 
ing our expectations and prediction of recovery. 

Treatment. — As typhoid fever is self-limited, the treatment required 
in ordinary cases is simple. It should be of a sustaining nature, both as 
regards diet and medicinal agents, and any untoward symptoms should be 
promptly. met by appropriate measures. The food should be in liquid 
form ; solid food is, indeed, in most cases, refused. Beef tea, milk, rice or 
barley-water, with milk, may be allowed from the first. Mild cases require 
no stimulants, still the moderate use of wine is not contraindicated in such 
cases, and may be allowed at an early period. In grave cases, character- 
ized by a dry and furred tongue, and quick and compressible pulse, 
milk-punch or wine-whey should be employed in suitable quantity at reg- 
ular intervals. 

When the fever is mild and pursuing its normal course, one of the 
mineral acids, as the dilute muriatic, or even a simple febrifuge may be 
employed, as spts. cetheris nitrosi, with syrup of ipecacuanha. 

R. Spts. aether, nit., ^ij. 
Syr. ipecac, 51 ij. 
S3T. simplic, 3Jss. Misce. 
Dose, one teaspoonful every three hours to a child of six years. 

If the febrile movement is considerable, or if it has distinct evening 
exacerbations, quinine is indicated, and in asthenic cases it may be em- 
ployed in smaller doses as a tonic. In such conditions it will be found 
useful. In cases attended with great restlessness or delirium, an appropri- 
ate dose of bromide of potassium or hydrate of chloral at night, will pro- 
cure rest, and be followed by no unfavorable result. I prefer the hydrate 
of chloral given in a small dose. A single dose of two or three grains of 
this agent will generally be sufficient. For the diarrhoea, I ordinarily 
prescribe paregoric, with half its quantity of the fluid extract of catechu 
in chalk mixture. The state of ansemia which is present in the advanced 
disease and in convalescence requires the employment of iron. The citrate 
of iron and quinine will, under such circumstances, be found useful. 



CEREBRO-SPINAL FEVER. 275 



CHAPTER IV. 



CEREBKO-SPINAL FEVEE. 



Cerebro-spinal fever, designated also spotted fever, tetanoid fever, and 
cerebro-spinal meningitis, is an epidemic constitutional disease, manifesting 
itself by lesions and symptoms which pertain chiefly to the nervous system. 
Descriptions of occasional epidemics, which appear to have been of this 
malady, have been left us by writers as far back as the fifteenth century, 
but it was not clearly disci'iminated from typhus on the one hand, and local 
inflammatory afl^ections of the cerebro-spinal axis on the other, till after 
the present century commenced. 

Few diseases more urgently demand elucidation than this, for while it 
is very fatal, there is a discrepancy in the views of physicians in regard to 
its causes, nature, and proper treatment. As cerebro-spinal fever results 
from some pervading cause, probably as we will see atmospheric, we would 
expect to observe effects of this cause, in some other way, in addition to 
the disease of which we are treating. Accordingly, the histories of at least 
a portion of the epidemics of cerebro-spinal fever show an unusual preva- 
lence of pneumonias of an ataxic type, and sometimes also of pharyngitis, 
in addition to the cerebro-spinal disease, aud this disease is sometimes com- 
plicated by congestion, and less frequently by inflanimation of the lungs. 
The prevalence of typhoid pneumonias during cerebro-spinal fever was 
long ago observed. Thus, in Bascome's history of epidemics, it is stated 
that "epidemic encephalitis and malignant pneumonias prevailed in Ger- 
many (Webber) in the sixteenth century." In this country, in the epidemics 
of cerebro-spinal fever from 1811 to 1815, pharyngeal and pneumonic in- 
flammations were unusually frequent. In more recent epidemics observers 
have not so often, but have occasionally, recorded the prevalence of pneu- 
monias in connection with cases of the cerebro-spinal disease. Accordingly, 
Webber, who has examined the histories of the various epidemics, describes 
in his prize essay a second variety of cerebro-spinal fever, which he desig- 
nates pneumonic, in which the cerebro-spinal axis is involved but slightly, 
or not at all, and the brunt of the disease falls upon the respiratory organs. 
In certain epidemics, according to him, the pneumonic form is common, 
while in others it is infrequent. 

During the time when the recent epidemic in New York City was at its 
maximum, an unusually large number of cases of pleuro-pneumonia of an 
asthenic type, and I may add, I think, of pharyngitis, occurred ; aud while 



276 CEREBRO-SPINAL FEVER. 

cerebro-spinal fever rarely affected those above the age of fifty years, many 
of those with pneumonia were okl people. According to the statistics of 
the New York Health Board, there were 1707 deaths from diseases of the 
respiratory organs, exclusive of phthisis, during the four months from 
February 1st to June 1st, 1872, when the epidemic of cerebro-spinal fever 
was at its height, while during the remaining eight months of the year 
there were only 1336 deaths from the same diseases; and I need not add 
that deaths from affections of the respiratory apparatus are largely from 
pneumonia. Moreover, I am of opinion, from my own observations, that 
many of the cases of pneumonia, during that period, presented symptoms 
of greater gravity than usually accompany this form of inflammation of 
the same extent. The patients were greatly prostrated from the first, and 
in some of them febrile movement, muscular pains, restlessness, or delirium 
preceded for hours or even days the pneumonic symptoms, affording evi- 
dence that the lung disease, if not due entirely to the same atmospheric 
conditions which give rise to cerebro-spinal fever, was at least under their 
influence. Although it is probable that pneumonia occurring during an 
epidemic of cerebro-spinal fever is in most instances a strictly local malady, 
as it is at ordinary times, more or less modified perhaps by the epidemic 
influence, there can be little doubt that AVebber's view is correct, that there 
are occasional cases of true cerebro-spinal fever, in which the local mani- 
festations are chiefly in the lungs ; cases in which the cerebro-spinal affec- 
tion is of less importance apparently than the pulmonic. I might relate 
striking examples, observed in the New York epidemic of 1872. 

In one case three prominent physicians, one of them known throughout 
the country as an excellent diagnostician, pronounced the disease cerebro- 
spinal meningitis, but on the sixth day, the cerebro-spinal symptoms hav- 
ing considerably abated, pneumonia occurred, and afterwards the pulmo- 
nary symptoms predominated. 

Cause. — Does the came of cerebrospinal fever emanate from the soil? 
Facts show that it does not. Most of the epidemics commence in winter 
when the ground is frozen ; the disease occurs in valleys, and on hilltops, 
and upon all varieties of soil ; it invades one district, passes over another 
adjoining, and affects, perhaps, a third beyond, although the geological 
formation of all is the same. 

Does the cause exist in the diet, as some competent observers have sup- 
posed ? The following facts, I believe, are sufiicient to justify a negative 
answer: Of two adjacent localities, in which the nature of the diet of the 
inhabitants is the same, one escapes and the other is visited by the epi- 
demic ; an epidemic sontetimes prevails here and there over an area of 
many thousand miles, as recently in North America. Jt is hardly reason- 
able to suppose that any deleterious property would occur in the food over 
so wide a territory. An epidemic ceases, although the food of the people 
continues the same. Infants at the breast, having only the mother's milk, 



CAUSE. 277 

are sometimes afFeeted, and likewise certain animals, whose food is very- 
different from that of man, and finally the most careful examinations have 
hitherto failed to discover any change in the cereals, or other food, or nox.- 
ious principle sufficient to explain the occurrence of the disease over a 
wide extent of territory. 

There can, therefore, be little doubt that the cause exists in the atmos- 
phere, though so subtle that we may never be able to detect it. Cerebi'o- 
spinal fever is indeed one of many examples in corroboration of the state- 
ment made by Humboldt, that there is no subject of scientific inquiry 
more obscure than the laws which control epidemics. Among the meteor- 
ological conditions which favor the occurrence of this disease, cool weather 
has already been alluded to. Statistics collected in France and the United 
States show that, while 166 epidemics occurred in the six months com- 
mencing with December, only 50 occurred in the remaining six months of 
the year. According to Professor Hirsch, whose statistics were obtained 
largely from Central Europe, there were 57 epidemics in winter or winter 
and spring, 11 in spring, 5 between spring and autumn, 4 commencing in 
autumn and extending into winter or winter and spring, and 6 lasting 
through the entire year. 

All observers have remarked the fact that anti-hygienic conditions, 
though obviously suboi'dinate to the unknown atmospheric cause, never- 
theless strongly predispose to this disease. Hence, soldiers in barracks 
and the poor in tenement houses suffer most severely. During the recent 
epidemic in New York, unusually severe or multiple cases occurred for the 
most part where there were obvious anti-hj'gienic conditions, as in apart- 
ments which were unusually crowded and filthy, or in tenements around 
which refuse had collected or which had defective drainage. The inter- 
esting chart, prepared under the direction of Dr. Moreau Morris for the 
Health Board, shows that comparatively few cases occurred in those por- 
tions of the city where the sanitary conditions were good. I cannot, how- 
ever, agree with Professor Hirsch that the greater crowding, domiciliary 
and personal uucleanliness, and imperfect ventilation in the cool than in 
the warm months, explain the fact that epidemics occur chiefly in w'inter 
and early spring; for in clean and well-ventilated apartments, in sparsely 
settled and salubrious localities, epidemics occur for the most part in these 
seasons. Anti-hygienic conditions probably predispose to this disease in 
the same way, and no more than to any other grave epidemic which hap- 
pens to be prevailing, as, for example, to Asiatic cholera, whose ravages 
are largely in the crowded and uncleanly quarters of the poor. 

Is eerebro-spinal fever propagated by contagionf — It is the almost unani- 
mous opinion of those who are most competent to judge from their obser- 
vations, that it is either not contagious or is so only in a very slight 
degree. It is certain that the vast majority of cases occur without the 
possibility of personal communication. Thus, in the commencement of an 



278 CEREBRO-SPINAL FEVER. 

epidemic, the first patients are affected here and there at a distance from 
each other, often miles apart, and throughout an epidemic usually only 
one is seized in a family. Children may be around the bedside of the 
patient, passing in and out of the room without restriction, and yet Ave 
can confidently predict that none of them will contract the disease if there 
are proper ventilation and cleanliness. And when two or more cases oc- 
cur in a family, it commences at such irregular intervals in the different 
patients that the presumption is strong that they receive it from the same 
extraneous source, and not one from the other, for contagious diseases 
usually have a pretty uniform incubative period. Thus, in the Brown 
family, treated by the late Dr.Sewall (iV. Y. Med. i?ec., July, 1872), the first 
child sickened January 30th, and the remaining five children at intervals 
respectively of 5, 7, 11, 25, and 45 days. The following have been my 
observations relating to this point : 

Single cases, No. 39 (4 adults). 

Two in a family. No. 16 (8 families). 

Three in a family. No. 3 (1 family). 

In most of the 39 families in which single cases occurred, there were 
children who were allowed free intercourse with the patients. Is there 
any other malady of childhood known to be infectious, which affords such 
a record of non-contagion ? In those instances in which two in a family 
took the fever, those who were last attacked did not seem to receive it 
from those who were first affected, for the reason already stated, namely, 
the very variable intervals between the two cases in the different families. 
The facts, in the family in which three cases occurred, did seem to lend 
support to the doctrine of contagion. A boy, twelve years of age, died of 
cerebro-spinal fever, and was buried on Saturday or Sunday. On the 
following Monday the mother washed the linen of the boy, which had 
accumulated, and within two days was herself affected with the disease. 
She and her infant, who was also seized with it, died. Were such cases 
frequent or not infrequent, the argument in favor of contagion would cer- 
tainly be strong ; but as they are infrequent it is proper to accept any 
other reasonable explanation instead. The state of the bedding and 
apartments, as observed by me, was such as to render the atmosphere in 
which this family lived noxious in a high degree, and therefore such as to 
attract the prevailing epidemic. Moreover, the mother, exhausted by her 
long watching, and deprived of needed sleep (for the boy was several days 
sick), instead of obtaining the required rest, rendered her system more 
liable to the fever by her self-imposed duties on the day following the 
burial. These manifest anti-hygienic conditions appeared quite sufficient, 
without the aid of any contagious principle, to explain the occurrence 
of the cases in this severely visited family. My statistics, therefore, har- 
monize with the doctrine of non-contagiousness, but it is obviously very 
difficult to determine from clinical experience whether an epidemic con- 



CAUSE. 279 

stitutioual disease is absolutely uon-contagious, or contagious in a very 
low degree. Cerebro-spinal fever is one or the other, but if contagious it 
is apparently less so than either typhoid fever or Asiatic cholera. 

Allusion has been made to the fact that this malady sometimes occurs 
among the lower animals. In the epidemic of 1811, in Vermont, Dr. 
Gallop remarks that even the foxes seemed to be affected, so that they 
were killed in numbers near the dwellings of the inhabitants. The recent 
epidemic in New York, it is well known, prevailed among horses several 
months before it occurred among the people. It was common and fatal 
in the large stables of the city car and stage lines in 1871, while among 
the people the epidemic did not properly commence, although there were 
previously isolated cases, till January, 1872. It has been asked whether 
in epidemics like this, in which the lower animals are first affected, the 
disease may not be communicated from them to man ? This obviously 
brings up the question of contagiousness. From my own observations I 
should certainly answer in the negative, for I have not been able to ascer- 
tain that those who had charge of the affected horses in the recent epi- 
demic, as the veterinary surgeons or stablemen, were any more liable to 
the fever than others who were not so exposed. They apparently were 
not, and we must, therefore, believe that this disease is not propagated 
from one species of animals to another, certainly no more than from one 
animal to another in the same species, and the fact that different animals 
are affected by the epidemic is due to the potent and pervading nature 
of the cause. Cerebro-spinal fever is indeed, so to speak, pandemic in a 
double sense ; on the one hand affecting both sexes, different ages, and all 
conditions of people over a wide extent of territory, and on the other 
hand different species of animals, but with little or no contagiousness. 

Not infrequently we are able to discover some exciting cause of the 
fever, usually an exhausting or perturbating influence of some sort. An 
individual whose system is affected by the epidemic influence, and is there- 
fore predisposed to the disease, may, perhaps, escape by a quiet and regu- 
lar mode of life ; but if there is an exciting cause of the nature alluded 
to, the fever may be developed. Among these exciting causes may be 
mentioned overwork, fatigue, mental excitement, prolonged abstinence 
from food, followed by over-eating, and the use of indigestible and im- 
proper food. Thus in one instance in my practice, a delicate young 
woman at the head of one of the departments in a well-known Broadway 
store, was anxious and excited and her energies overtaxed at the annual 
reopening. Within a day or two subsequently the disease commenced. 
Another patient, a boy, was seized after a day of unusual excitement and 
exposure, having in the meantime bathed in the Hudson when the weather 
was quite cool. During the recent epidemic in New York those children 
seemed to me especially liable to be attacked who were subjected to the 
severe discipline of the public schools, returning home fatigued and hungry, 



280 CEREBRO-SPINAL FEVER. 

and eating heartily at a late hour. In one instance which I observed, a 
school girl of ten years returned from school excited and crying, because 
she had failed in her examination and was not promoted. In the evening, 
after she had closely studied her lessons, the fever commenced with violent 
headache. Dr. Frothingham (Am. Med. Times, April 30th, 1864) writes as 
follows of the brigade in which cerebro-spinal fever occurred in the Army 
of the Potomac: "Under Gen. Butterfield, a stern disciplinarian .... 
the men were drilled to the full extent of their powers — often to exhaus- 
tion. I did not at the time recognize this as a cause of the disease in 
question, but I learn that in the present epidemic in Pennsylvania the 
attack generally follows unusual exertion and exposure to cold." Observ- 
ers have long recognized the fact of such exciting causes. Dr. Gallop, in 
his history of the epidemic in Vermont in 1811, directs attention to the 
severity of the disease among the troops under General Dearborn, who 
were fatigued by marches, and greatly dispirited by a repulse which they 
had sustained from the British. 

Sex. — It is stated by writers that more males are affected than females. 
Hospital and military statistics show this ; but in family practice, in which 
a large proportion of the patients are children, the number of males and 
females is about equal. Thus in 75 cases occurring in the 20th and 22d 
wards, mainly in the practice of two other physicians and myself, I find 
that there were 39 males and 36 females. Sixty-four of these were chil- 
dren. From January 1st to November 1st, 1872, 905 cases in which the 
sex was stated were reported to the Health Board. Of these 48 t were 
males, and 421 females. Dr. Sanderson's statistics of the epidemic in the 
provinces around the Vistula, the cases being chiefly children, give also 
but a slight excess of males. Probably, therefore, the sex under the age 
of puberty makes no difference in the liability to this disease, and the 
same may be said of all other constitutional affections. Men are more 
liable thaii women, only when they lead a more irregular life, and are 
subject to more privations and exposures. 

Age. — Children, as already stated, are much more liable to cerebro- 
spinal fever than adults. The following are the statistics of the Health 
Board relating to this point, the cases occurring in 1872: 

Under 1 year, 12-5 

From 1 to 5 year.?, ........ 386 

" 5 " 10 " 204 

" 10 " 15 " . . 106 

" 15 "20 " 54 

" 20 " 30 " 79 

Over 30 years, 71 

Total, 975 



SYMPTOMS. 281 

In the statistics which I have obtained of 81 cases occurring in the 20th 
and 22d wards, the ages were as follows : 

Under 1 year, ......... 8 

From 1 to 3 years, 18 

" 3 " 5 " . 20 

" 5 " 10 " 17 

" 10 " 15 " 7 

Over 14 years, . .11 

Total, 81 

It is seen that nearly threcrfourths of the whole number of cases in the 
recent epidemic in New York City were under the age of ten years. The 
statistics of other epidemics occurring in civil practice is similar. Thus 
Dr. Sanderson, in examining the mortuary statistics of the epidemic in 
Germany, ascertained that there had been 218 deaths under the age of 
fourteen years, and only 17 above that age, and although this does not 
show the exact ratio of children to adults, in the entire number of cases it 
is apparent that children greatly preponderated. 

The more advanced the age after childhood, the less the liability to this 
malady ; so that after the middle period of life few cases occur, and after 
the age of fifty years there is nearly an immunity. The oldest two in 
the recent epidemic, of whose cases I have the records, had attained the 
ages respectively of 47 and 63 years. 

Symptoms. — During epidemics of cerebro-spinal fever, we are now and 
then called to patients who present certain of the characteristic symptoms, 
but in so transient and mild a form that they are soon restored to health. 
The fever is said to have aborted. I have met the following cases : 

A boy of eight years, previously well, was taken with headache, vomit- 
ing, and moderate febrile movement on April 2d, 1872. The evacuations 
were regular, and no local cause of the attack could be discovered. On 
the following day the symptoms continued, except the vomiting, but he 
seemed somewhat better. On April 4th the febrile movement was more 
pronounced, and in the afternoon he was drowsy and had a slight convul- 
sion. The forward movement of his head was apparently somewhat 
restrained. On the 6th the symptoms had begun to abate, and in about 
one week from the commencement of the attack his health was fully 
restored. 

A boy aged six years, was well till the second week in May, 1872, when 
he became feverish, and complained of headache. At my first visit. May 
14th, he still had headache, with a ])ulse of 112. The pupils were sensi- 
tive to light, but the right pupil was larger than the left. The bromide and 
iodide of potassium were prescribed with moderate counter-irritation be- 
hind the ears. The headache and febrile movement in a few days abated, 
the equality of the pupils was restored, and within a little more than a 
week from the first symptoms he fully recovered. 



282 CEREBRO-SPINAL FEVER. 

Obviously the diagnosis, when symptoms are so mild, must sometimes 
be doubtful ; but as observers in different epidemics report such cases, it 
seems proper to regard them with perhaps occasional exceptions as genuine, 
but aborted cases. The epidemic influence acts so feebly on these ])atieuts, 
or their ability to resist it is so great, that they escape with a short and 
trivial ailment. 

Occasionally, also, during the progress of an epidemic, we meet patients 
who present more orfewer of the characteristic symptoms, but in so mild a 
form that they are never seriously sick, and never entirely lose the appe- 
tite, but the disease, instead of aborting, continues about the usual time. 

Thus, on the 4th of January, 1873, 1 was called to a girl of thirteen years, 
who had been seized with vomiting followed by headache in the last week 
in December. During a period of six to eight weeks, or till nearly the 
1st of March, she presented the following symptoms: Daily paroxysmal 
headache, often most severe in the forenoon ; neuralgic pain in the left hy- 
pochondrium, and sometimes in the epigastric region; pulse and tempera- 
ture sometimes nearly normal, and at other times accelerated and elevated, 
both with daily variations ; inequality of the pupils, the right being larger 
than the left during a portion of the sickness. This patient was never so 
ill as to keep the bed, usually sitting quietly during the day in a chair, or 
reclining on a lounge, and she never fully lost her appetite. Quiuia had 
no appreciable effect on the paroxysms of pain or fever. 

There can, in my opinion, be little doubt that this girl was affected by 
the epidemic, but so mildly that there was, for a considerable time, much 
uncertainty in the diagnosis. Cases like this, in which the disease is so 
feebly developed, and those in which it aborts, though they deserve recog- 
nition, evidently should not be employed in the statistics. 

Mode of Commencement. — In all the cases which I have observed, 
cerebro-spinal fever commenced between 12 M. and 6 A.M., and iu the 
records of cases published by others the time of commencement, so far as 
I have observed, was between the same hours. The fact that this disease 
does not commence after the repose of night till several hours of the day 
have passed, shows the propriety, as we shall see hereafter, of enjoining a 
quiet and regular mode of life, free from excitement, and with sufficient 
hours of sleep during the time that the epidemic is prevailing. 

Cerebro-spinal fever usually has no premonitory stage, or it is so slight 
as to escape notice. Exceptionally there are certain premonitions for a 
few hours or days, such as languor, chilliness, etc. Premonitions occur 
more frequently in mild than in severe forms of the fever. The ordinary 
mode of commencement in a typical or somewhat severe case is as follows: 
The patient has a rigor or chill, or rarely two or three of them at irregular 
intervals of some hours. One j)atient, an adult female, had three or four 
pretty severe chills, the last occurring, from recollection, as late as the 



SYMPTOMS. 283 

fourth day. Children often have clonic convulsions in place of the chill, or 
immediately after it, partial or general, slight or severe. Apathy, more or 
less profound stupor, or less frequently delirium succeeds. In the gravest 
cases semi-coma occurs, from which the patient is with difficulty aroused, 
or profound coma, which, in spite of prompt and appropriate treatment, 
may prove speedily fatal. If aroused to consciousness, he now complains 
of violent headache, with or without, or alternating with equally severe 
neuralgic pains in the neck, some part of the trunk, or in one of the ex- 
tremities. The pupils are dilated, or less frequently contracted, and they 
respond feebly, or not at all, to light. Often they oscillate, and occasion- 
ally one is larger than the other. 

Vomiting, with little apparent nausea, is also an early and prominent 
symptom, evidently having a cerebral origin. It occurred as an initial 
symptom in 51 of 56 cases observed by Dr. Sanderson. Of 61 cases 
observed by Dr. Sewall and myself, neither its presence nor absence was 
recorded in 13 cases, its absence in only 1, and its presence as an early 
symptom in 48 cases. 

Unlike typhus and typhoid fevers the temperature is usually as elevated, 
and sometimes more so, on the first day than subsequently. Indeed, the 
highest temperature which I have observed in any case, was only two or 
three hours after the commencement of the attack in a child of three 
years, namely, a temperature of 107f °. 

Exceptionally the initial symptoms occur in a more gradual manner, 
becoming by degrees more severe, so that a few days elapse before they are 
so pronounced that a clear diagnosis is possible. The febrile movement, 
headache, neuralgic pains, lassitude, vomiting, and fretfuluess, though 
pretty uniformly present in the commencement, are not in these cases so 
severe at this period as to excite any apprehension. 

Symptoms pertaining to the Nervous System. — Pain, already de- 
scribed as an initial symptom, continues during the acute period of the 
malady. It is ordinarily severe, eliciting moans from the suflferer, but its 
intensity varies in different patients. Its most frequent seat is the head, 
where it may be frontal or occipital. It is described as sharp, lancinating, 
or boring. It is also common in the neck, especially the nucha, the epigas- 
trium, umbilical and lumbar regions, in one or more of the limbs, and 
along the spine (rachialgia). It shifts from place to place, but it is com- 
monly more persistent in the head and along the spine than elsewhere. 
The patient, if old enough to speak, and not delirious or too stupid, often 
exclaims, " Oh my head !" from the intensity of his suffering, but after some 
moments complains e(|ually of pain in some other part, while perhaps the 
headache has ceased, or is milder. In a few instances the headache is ab- 
sent, or is slight and transient, while the pain is intense elsewhere. After 
some days the pains begin to abate, and by the close of the second week 



284 CEREBRO-SPINAL FEVER. 

they are much less pronounced than previously- Vertigo occurs with the 
headache, so that the patient reels in attempting to stand or walk. Con- 
tributing to the unsteadiness of the muscular movements is a notable loss 
of strength, which occurs early and increases. 

The state of the patient's mind is interesting. It is well expressed in or- 
dinary cases by the term apathy or indifference, and between this and coma 
on the one hand, and acute delirium on the other, there is every gradation 
of mental disturbance. Sometimes patients seem totally unconscious of 
the words or presence of those around them, when it appears subsequently 
that they understood what was said or done. Delirium is not infrequent, 
especially in the older children and adults. Its form is various, most fre- 
quently quiet or passive, but occasionally maniacal, so that forcible restraint 
is required. It sometimes resembles intoxication, or hysteria, or it may 
appear as a simple delusion in regard to certain subjects. Thus one of my 
patients, a boy of five years, appeared for the most part rational, protruding 
his tongue when requested, and ordinarily answering questions correctly, 
but he constantly mistook his mother, who was always at his bedside, for 
another person. Severe active delirium is commonly preceded by intense 
headache. In favorable cases the delirium is usually short, but in the 
unfavorable it is apt to continue w'itli little abatement till coma super- 
venes. 

On account of the pain and disordered state of mind, patients seldom re- 
main quiet in bed, unless they are comatose, or the disease is mild, or so 
far advanced that muscular movements are difficult from weakness. In 
severe cases they are ordinarily quiet a few moments as if slumbering, and 
then, aroused by the pain, roll or toss from one part of the bed to another. 
One of my patients, a boy of five years, repeatedly made the entire circuit 
of the bed during the spells of restlessness. In mild cases patients lie quiet, 
usually with their eyes closed, except when disturbed. 

All writers record a general hyper?esthesia of the skin. Few patients 
that are not in a state of profound coma are free from it during the first 
weeks, and it increases materially the suffering. Frictions upon the sur- 
face, and even slight pressure with the fingers upon certain parts, extort 
cries. Gently separating the eyelids for the purpose of inspecting the eyes, 
and moving the limbs, or changing the position of the head, evidently in- 
crease the suffering, and are resisted. I have sometimes observed such 
outcries from slowly introducing the thermometer into the rectum, that I 
was forced to believe that the anal, and perhaps rectal, surface was also 
hypersensitive. The hypersesthesia has diagnostic value, for there is no 
disease with which cerebro-spinal fever is likely to be confounded in which 
it is so great. It is due to the spinal meningitis, and is appreciable even 
in a state of semi-coma. 

Tonic contraction of certain muscles, or groups of muscles, is present in 
all typical cases. In a small proportion of patients it is absent, or is not a 



SYMPTOMS. 



285 



prominent symptom, namely, in those in whom the encephalon is mainly 
involved, the spinal cord and meninges being but slightly affected, or not 
at all. This contraction is most frequent and marked in the muscles of the 
nucha, causing retraction of the head, but it is also common in the poste- 
rior muscles of the trunk, producing opisthotonos, and in less degree in 
those of the abdomen and lower extremities, and hence the flexed posi- 
tion of the thighs and legs, in which patients obtain most relief. The aius- 




cular contraction is not an initial symptom. I have ordinarily first ob- 
served it about the close of the second day, but sometimes as early as the 
close of the first day, and in other instances not till the close of the third 
day. Attempts to overcome the rigidity, as by bringing forward the 
head, are very painful, and cause the patient to resist. In young chil- 
dren having a mild form of the fever with little retraction of the head, 
the rigidity is sometimes not easily detected. I have been able in these 
cases to satisfy myself and the friends of its presence, by observing the 
difficulty with which the head is brought forward on presenting to the 
patient a tumbler with cold water, which is craved on account of the thirst. 
The usual position of the patient in bed is with the head thrown back, 
the thighs and legs flexed, with or without forward arching of the spine 
(see figure). The muscular contraction continues from three to five weeks, 
more or less, and abates gradually; occasionally it continues much longer. 
Through the kindness of Dr. Griswold, of Thirtieth Street, I was allowed 
to see an infant of seven mouths in the tenth week of the disease. It ex- 
hibited great fretfulness, decided prominence of the anterior fontanelle, 
probably from intracranial serous efl'usion, and marked rigidity of the 
muscles of the nucha with retraction of the head. 

Paralysis occasionally occurs, but is less frequent than we would be led 
to expect from the nature of the lesions. It may occur early, but it is 
more frequently a late symptom. It may be limited to one or two of the 
limbs, as a leg, or arm and leg, or it may be more general. Thus a man 



286 CEREBRO-SPINAL FEVER. 

treated by Dr. Law in the Dublin epidemic of 1865 could move neither 
arms nor legs, and Wunderlich saw a patient who had paralysis of both 
lower extremities and a considerable part of the trunk. As the paralysis 
is due to inflammatory processes in the cerebro-spinal axis, it usually dis- 
appears in a few weeks as the inflammation abates, and convalescence is 
established, but it may be more protracted. Thus in Wunderlich's case 
there was only partial recovery after the lapse of five months. 

Digestive System. — The tongue is ordinarily lightly covered with a 
whitish fur. Occasionally in cases attended with great prostration the 
fur is dry and brown, but only for a few days, when the moist whitish 
fur succeeds. The habitual brownish and dry fur on the tongue, and 
sordes upon the teeth, so common in typhus and typhoid fevers, are seldom 
observed in uncomplicated cases of this disease. Vomiting, which I have 
described as an initial symptom, usually ceases in a few hours, or not till 
the lapse of several days, and it frequently recurs at intervals during the 
periods of recrudescence, which are common in the progress of the fever. 
It occurs with little effort, often like a regurgitation, as is common when 
this symptom has a cerebral origin. The ejecta consist at first of the con- 
tents of the stomach, and afterwards partly of bile. It does not differ as 
a symptom from the vomiting which is so common in sporadic meningitis. 
Having a similar origin is a sensation of faintness or depression referred 
to the epigastrium. 

The appetite is poor or entirely lost during the active period of the 
malady, and it is not fully restored till convalescence is well advanced. 
On account of the imperfect nutrition, patients progressively waste, and 
when the case is protracted there is always notable emaciation. Thirst, 
already alluded to, and more or less constipation are common, but the 
latter readily yields to purgatives. On the other hand diarrhoea some- 
times precedes, and accompanies the disease. I observed this in a few in- 
stances in 1872, when the weather had become warm. The patients were 
young children. 

Pulse. — The pulse in children is constantly accelerated. Even in mild 
cases it is rarely below 100 per minute, and its ordinary range is from 112 
to 160. I have seventy-five recorded observations of the pulse in children 
who recovered, taken before there was any decided improvement. The 
maximum pulse in these observations was 168 per minute, which was on 
the first day ; the minimum 82, and the average 123. The more severe 
and dangerous the attack, the greater the frequency of the pulse, unless 
occasionally in the comatose state. But even in profound coma the pulse 
was in my observations accelerated, and as death grew near, however great 
the stupor, it was progressively more frequent and feeble. Intermissions 
in the pulse do not seem to be as frequent as in sporadic meningitis. The 
pulse is liable to daily variations in frequency, which occur suddenly and 
without appreciable cause. The following consecutive enumerations of the 



TEMPEEATUEE. 287 

pulse in four favorable cases which I have selected as typical will give an 
idea of these variations : 

1st case, an infant of 14 months, 168, 120, 108, 120, 140, 150, 136, 128, 
120. 

2d case, an infant of 2 years, 136, 152, 130, 132, 136, 140, 152, 140, 
136, 148. 

3d case, a boy of 6 years, 120, 120, 88, 84, 92, 124, 128, 120. 

4th case, a girl of 4 years, 116, 100, 124, 116, 120, 136, 140, 128, 128, 
104. 

I have preserved observations of this symjDtora made daily in nine fatal 
cases, and these show similar fluctuations in the frequency of the heart's 
contractions. The patients were children, all dying comatose. The maxi- 
mum pulse in these observations was 204, which was on the first day ; the 
minimum 88, and the average 140. The following are the consecutive 
enumerations of the pulse usually made twice daily in two of these cases. 
It will be seen that there was not only greater frequency of the pulse, but 
fluctuations from day to day similar to those in the favorable cases : 

1st case, age 8 months, 204, 164, 116, 160, 164. 

2d case, age 2 years 8 months, 192, 168, 200, 152, 160. 

In most inflammatory and febrile diseases exacerbations commonly 
occur in the latter part of the day, but in this disease they do not seem 
to be influenced by the time of day, so that sometimes the temperature is 
highest and pulse most frequent in the morning, sometimes in the evening, 
and then again at midday. 

In favorable adult cases the pulse often remains under 100, and in cer- 
tain patients it scarcely has more than the normal frequency, but if the 
type is severe it rises to 110, 120, or over. In the adult, as in the child, 
as death approaches, the pulse becomes more and more frequent and feeble, 
and it seldom even in the most asthenic cases has the fulness and force ob- 
served in idiopathic inflammations. 

Temperature. — Certain of the older observers before the day of clini- 
cal thermometry asserted that the temperature is not increased. North 
remarked as follows : " Cases occur, it is true, in which the temperature is 
increased above the normal standard, but these are rare ;" and Foot and 
Gallop made similar statements. I am surprised also that some of the 
recent writers state that febrile movement is often absent. Thus, in a 
well-written American treatise, bearing the date 1873, it is stated "that 
febrile symptoms do not necessarily belong to epidemic cerebro-spinal men- 
ingitis as a substantive disease, for it may and not unfrequently does occur 
without exhibiting any such symptoms." (Lidell.) 

I have no doubt from the nature of cerebro-spinal fever, and from ther- 
mometric examinations, which I have made now in more than fifty cases, 
that there is always an elevation of the internal temperature above the 



288 CEREBRO-SPINAL FEVER. 

normal staudard diiriug the active period of the disease. I have uever 
observed a temperature of less than 99^^ if the examination were made 
within the first fourteen days, and the reason that certain other observers 
state differently is probably because they have taken the temperature of 
the cutaneous surface, which is very fluctuating and is often much below 
that of the blood. The temperature should be ascertained per rectum, 
where it corresponds pretty neafi-ly with that of the blood. In one instance 
I supposed that I had met a case in which the temperature was not ele- 
vated, and I cite it as showing the liability to error in the thermometric 
examinations of these cases : A female patient, forty-seven years old, three 
days sick and comatose, whom I was allowed to examine with the family 
physician, exhibited no elevation of temperature when the instrument was 
placed in the mouth and the axilla, but on introducing it into the rectum 
it rose to 99^°. 

The internal temperature, although uniformly elevated, undergoes greater 
and more sudden variations than occur in any other febrile or inflammatory 
disease. These fluctuations, which correspond with similar changes in the 
pulse, are observed during the different hours of the same day. I have in 
the statistics of my practice 146 observations of the temperature in 35 pa- 
tients taken before the close of the second week. The highest I have already 
stated in speaking of the mode of commencement, namely 107|-° in a child 
of two years. It fell a little subsequently, but rose again on the third day 
to 107°, when she died. In two other cases the temperature was 106^ on 
the first day, and it did not afterwards reach so high an elevation. One 
of these died on the ninth day, and the other in the ninth week. The 
next highest temperature was 105|-°, also on the first day, in an infant of 
eight months, who died on the ninth day. The first and last of these 
cases occurred in the same wooden tenement-house in the suburbs of the 
city and upon an elevated outcropping of rock. Wunderlich has recorded 
a temperature of 110^ in one or two cases, but so great an elevation must 
be very rare in cerebro-spiual fever, and is of course prognostic of an un- 
favorable ending. 

The external temperature undergoes similar but greater fluctuations, 
rising above and falling below the normal standard several times in the 
course of the same day. Similar fluctuations occur in sporadic meningitis, 
but they are much less pronounced. The more grave the case in those 
not comatose, the greater these variations. The following is a common 
example : the patient was two years old, and the case was one of consider- 
able severity. The observations were made at four consecutive visits dur- 
ing the first week. The internal temperature varied from 10H° to 104|° 
as the extremes, while that of the fingers and hand at the first examina- 
tion was 90r, at the second 90°, at the third 103°, and at the fourth 83°. 
Thus the temperature of the extremities at the fii-st and second examiua- 
tions was about 8° below that of health, while at the third examination it 



CUTANEOUS SURFACE. 289 

had risen 13°, so as nearly to equal the internal temperature, and at the 
fourth examination it had again fallen 20°, or 15J° below the normal 
standard. The patient recovered. These sudden and great variations in 
the pulse and temperature have considerable diagnostic value in obscure 
and doubtful cases. 

Respiratory System. — The symptoms which are referable to the 
respiratory apparatus are for the most part quite subordinate except when 
an inflammatory complication occurs. The respiration in uncomplicated 
cases is quiet and easy, and a cough if present is usually slight and acci- 
dental. Intermittent, sighing, or irregular respiration is less frequent 
in cerebro-spiual fever than in sporadic meningitis, but it does occur. In 
ordinary cases the respiration is somewhat accelerated, but without any 
marked disturbance in its rhythm. In 31 observations in children who 
had the disease without complication, I found the average respirations 
42 per minute, while the average pulse was 137. It is seen therefore that 
the respiration as compared with the pulse was proportionately more 
frequent than in health. This appears to be due to the fact, that certain 
muscles, which are concerned in respiration, as the abdominal and per- 
haps others, are embarrassed in their movements by the tonic contractions. 
In cases of pulmonary congestion, oedema, or inflammation, of course, the 
symptoms of this aflTection are superadded to those of the primary disease. 

Cutaneous Surface. — The features may be pallid, of normal appear- 
ance, or flushed in the first days of the disease ; but in advanced cases 
they are pallid, as is the skin generally. A circumscribed patch of deep 
congestion often appears, as in sporadic meningitis, upon some parts of 
them, as the cheek, forehead, and ear, and after a short time disappears. 
Friction for a moment upon any part of the surface, when the temperature 
is not reduced, produces the same appearance, a fact to which Trousseau 
and others have called attention as regards sporadic meningitis. 

The following are the abnormal appearances of the skin which I have 
most frequently observed : 1st. Papilliform elevations, due to contraction of 
the muscular fibres of the corium, namely the so-called gooseskin. This is 
not uncommon in the first weeks. 2d. A dusky mottling, also common in the 
first and second weeks, in grave cases, and most marked where the tempera- 
ture is reduced. 3d. Numerous minute red points over a large part of the 
surface, bluish spots a few lines in diameter due to extravasation of blood 
under the cuticle, resembling bruises in appearance, and large patches of 
the same color, an inch or more in diameter, less common than the others, 
and usually not more than two or three upon a patient. These last I be- 
lieve from certain observations are sometimes the result of bruises, which 
the patients receive during the times of restlessness. 4th. Herpes. This 
is common. It sometimes occurs as early as the second or third day, but 
in other instances not till towards the close of the first week or in the 
second. The number of herpetic eruptions varies from six or eight to a 

19 



290 CEREBRO-SPIXAL FEVER. 

dozen or more. This affection evidently has a neuropathic origin, the 
vesicles occurring chiefly on those parts of the surface which are supplied 
by branches of the fifth pair of nerves. Its most common seat is upon the 
lips, but I have occasionally observed it upon the mucous membrane of 
the nasal and buccal surfaces, upon the cheek, around the ears and upon 
the scalp. 

During the first days the skin is apt to be dry. Afterwards perspira- 
tions are not unusual, and free perspirations sometimes occur especially 
about the head, face, and neck. The quantity of urine excreted is normal, 
or it may be in excess of the normal amount. It occasionally contains a 
moderate amount of albumen, and in exceptional instances cylindrical 
casts and blood-corpuscles. A deposit of urates in the urine is not infre- 
quent, but this so often occurs in inflammatory and febrile diseases, that 
it is of little moment. 

Arthritic inflammation, apparently of a rheumatic character, has been 
occasionally observed. It is commonly slight, producing merely an cedem- 
atous appearance around one or more joints. Thus, in one case which 
came under my notice, and which was subsequently fatal, the parents, 
who were poor, and were therefore without medical advice till the case 
was somewhat advanced, had already diagnosticated rheumatism on ac- 
count of puffiness, which they had noticed around one of the wrists. 

The organs of the special senses are more or less involved in most cases, 
and the eye and ear are not infrequently the seat of serious lesions. Taste 
and smell are rarely affected, so far as known, but it is possible that they 
may sometimes be perverted or even temporarily lost during the time of 
greatest stupor. In one case at least the smell in one nostril was entirely 
lost. The affections of the eye and ear are the most important and inter- 
esting of those of the special senses. Strabismus is common. It may 
occur at any period of the fever, continuing a few hours or several days, 
and it may appear and disappear several times before convalescence is 
established. Occasionally it continues several weeks, but with few excep- 
tions the parallelism of the eyes is finally I'estored. In a boy of five 
years, whom I last saw three months after convalescence, there was still 
•convergent strabismus of the right eye and double vision. 

Changes in the pupils are among the first and most noticeable of the 
initial symptoms, as I have already stated in describing the mode of com- 
mencement. These are dilatation, less frequently contraction, oscillation, 
inequality of size, feeble response to light, etc. Most patients present one 
or more of these abnormalities of the pupils, and they continue during the 
first and second weeks, and gradually abate as the condition of the patient 
improves. Inflammatory hyperremia of the conjunctiva often occurs. It 
commences early, and now and then, the conjunctivitis is so intense, that 
considerable tumefaction of the lids occurs, with a free muco-purulent se- 
cretion. The false diagnosis has indeed been made of purulent ophthalmia, 



ORGANS OF THE SPECIAL SENSES, 291 

in cases in which this affection of the lids was early and severe. But such 
intense inflammation is quite exceptional.' More frequently there is a 
uniform diffused redness of the conjunctiva, not so dusky as in typhus, and 
the injected vessels cannot be so readily distinguished as in that disease. 

In certain cases almost the whole eye (all, indeed, of the important con- 
stituents) becomes inflamed ; the media grow cloudy, the iris discolored, 
and the pupils uneven and filled up with fibrinous exudation. The deep 
structures of the eye cannot, therefore, be readily explored by the oph- 
thalmoscope, but they are observed to be adherent to each other, and cov- 
ered by inflammatory exudation. They present a dusky red, or even a 
dark color, when the inflammation is recent. Exceptionally, the cornea 
ulcerates, and the eye bursts, with a loss of more or less of the liquids and 
shrinking of the eye. But ordinarily no ulceration occurs, and, as the 
patient convalesces, the oedema of the lids, hypersemia of the conjunctiva, 
the cloudiness of the cornea, and of the humors, gradually abate, and the 
exudation in the pupils is absorbed. The iris bulges forward, and the 
deep tissues of the eye, viewed through the vitreous humor, which before 
had a dusky red color from hypersemia, now present a dull white color. 
The lens itself, at first transparent, after awhile becomes cataractous. 
Sight is lost, totally and forever. This form of ophthalmia is sometimes 
rapidly developed, as in the following example: 

On July 5th, 1873, I was called to a boy, five years of age, who had 
reached the tenth day of cerebro-spinal fever without apparently any 
affection of the eyes, as both presented the normal appearance. On the 
following day the left eye was red and swollen from the inflammation and 
chemosis, so that the lids could not be closed, and the media were cloudy. 
Death occurred on the same day. 

If the patient live, the volume of the eye diminishes, as the inflamma- 
tion abates, to less than the norrtial size, even when there has been no 
rupture, and divergent strabismus is apt to occur. Professor Knapp, 
whose description of the eye I have for the most part followed, says : 
" The nature of the eye affection is a purulent choroiditis, probably metas- 
tatic." Fortunately so general and destructive an inflammation of the 
eye, as has been described above, is comparatively rare. On the other 
hand, conjunctivitis of greater or less severity, and hypersemia of the 
optic disk, consequent on the brain disease, are not unusual, but they 
subside, leaving the function of the organ unimpaired. 

Inflammation of the middle ear of a mild grade, and subsiding without 
impairment of hearing, is common. The inembrana tympaui, during its 
continuance, presents a dull yellowish, and in places a reddish, hue. Oc- 
casionally a more severe otitis media occurs, ending in suppuration, perfo- 
ration of the membrana tympani, and otorrhoea, which ceases after a 
variable time. But otitis media is not the most severe affection of the 
sense of hearing. Certain patients lose their hearing entirely and never 



292 CEEEBRO-SPIXAL FEVER. 

regain it, and that too, with little otalgia, otorrhoea, or other local symp- 
toms, by Avhich so grave a result can be prognosticated. This loss of 
hearing does not occur at the same period of the disease in all cases. 
Some of those who become deaf are able to hear as they emerge from the 
stupor of the disease, but lose this function during convalescence, while 
the majority are observed to be deaf as soon as the stupor abates and full 
consciousness returns. 

Two important facts have been observed in reference to the loss of hear- 
ing in these patients, namely, it is bilateral and complete. When first 
observed it is sometimes complete, but in other instances it is partial, and 
when partial it gradually increases till after some days or weeks, when it 
becomes complete. I have the records of ten cases of this loss of hear- 
ing, or about one in ten of the total number of cases which have either 
come under my observation, or have been reported to me by physicians in 
whose practice they occurred. One was a young lady, and the others 
children under the age of ten years. Prof. Knapp has examined thirty- 
one cases. "In all," says he, "the deafness was bilateral, and with two 
exceptions, of faint perception of sound, complete. Among the twenty- 
nine cases of total deafness there was only one who seemed to give some 
evidence of hearing afterwards." 

One theory attributes the loss of hearing to inflammatory lesions, either 
at the centre of audition within the brain, or in the course of the auditory 
nerves before they enter the auditory foramina. Thus Stille says: "This 
symptom appears to depend chiefly upon the pressure of the plastic exu- 
dation in which the nerves are imbedded." The other theory attributes 
the loss of hearing to inflammatory disease of the ear, and especially of 
the labyrinth. Di\ Sanderson, who is an advocate of this latter theory, 
remarks as follows : "As regards the nature of the affection, there appears 
to be good reason for believing that, like the blindness observed under 
similar circumstances, and sometimes in the same cases, it is dependent on 
inflammatory changes in the organ of hearing itself Dr. Klebs was kind 
enough to show me in the pathological museum of the Charitie, at Berlin, 
a preparation of the internal ear of a soldier who had died of epidemic 
meningitis complicated with deafness, in which fibrinous adhesions existed 
between the bones of the internal ear and the walls of the vestibule. Dr. 
Klebs stated that in the recent state the mucous lining of the vestibule 
was detached." In the case of a young woman who was deaf from the 
commencement and died on the eighth day, "both tympana were natural, 
but in the left membrana tympani was found a dense white thickening as 
large as a pin's head. On the same side the lining membrane of the 
semicircular canals was distinctly thickened and loosened, and in the an- 
terior canal there were semifluid purulent masses." Professor Knapp 
also states: "The nature of the ear disease is, in all probability, a puru- 
lent inflammation of the labyrinth." According to him no disease of the 



I 



NATURE. 293 

middle ear could cause such complete deafness, and, as evidence that the 
deafness is not due to central disease. Dr. Gruening obtained by electri- 
zation the normal reaction of the auditory nerve within the cranium. 
Moreover, if the lesion which destroys hearing is within the cranium, why 
is not the function of the other cranial nerves also abolished. Drs. Keller 
and Lucae have also, in three post-mortem examinations, found evidences 
of disease of the labyrinth. 

An argument in support of the former of these theories is the fact, that 
the lesion which produces the deafness is not ordinarily attended by any 
marked subjective symptoms referable to the ear, as otalgia, etc. Again, 
the fact that the deafness is always bilateral and simultaneous in the two 
ears, comports better with the doctrine of a- central lesion than with that 
which locates the lesion in the ear. But the true theory can only be posi- 
tively established by dissections, and as we have seen, several post-mortem 
examinations have revealed inflammatory disease of the labyrinth in those 
who have died having this form of deafness, while in no case, so far as I 
am aware, has the ear been found free from inflammatory lesions. There- 
fore, the theory which ascribes the deafness to disease of the ear is much 
better established than the other, and in the present state of our knowl- 
edge we must accept it. Moreover, most of the aurists of this city, who 
have had excellent opportunities to examine these cases, believe in this 
theory. 

Nature. — If we examine the literature of cerebro-spinal fever we will 
find that three theories relating to its nature have been advocated : one 
that it is a local disease, occurring epidemically ; the second, that it is 
akin to typhus fever, or is a form of it ; and the third, that it is a disease 
sui generis. 

The first theory, that it is an epidemic local disease, once had many 
adherents, but it is now nearly discarded. Job Wilson, in 1815, consid- 
ered it a form of influenza, and he could discern no utility in drawing a 
distinction between spotted fever and influenza. We, in this day, can see 
no resemblance between the two, except that they are both pandemics. 
A more plausible view is, that it is merely an epidemic inflammation of 
the cerebral and spinal meninges. Even Niemeyer says that it presents 
no symptoms except such as are referable to the local affection. But a 
moment's thought will show us that cerebro-spinal fever differs as widely 
from simple meningitis, as scarlet fever with its pharyngitis differs from 
idiopathic pharyngitis. Cerebro-spinal fever begins abruptly, usually in 
those with previous good health ; and its initial symptoms, we have seen, 
are severe ; while sporadic meningitis ordinarily occurs in those of feeble 
or failing health, with an insidious approach, and with gradually increasing 
symptoms. And though the two diseases have many symptoms in common, 
they differ in others. Scantiness of the urine, dryness of the skin and 
retraction of the abdomen, are observed in sporadic meningitis, while a 



294 CEREBRO-SPINAL FEVER. 

normal or increased amount of urine, a normal or even rounded fulness 
of the abdomen, and often, also, perspiration, are symptoms of cerebro- 
spinal fever. The two diseases differ also strikingly as regards the periods 
of greatest danger and the prognosis ; but the conclusive proof that the 
disease of which we are treating is not a local affection, but constitutional, 
with local manifestations, is found in the fact of a constant and early blood 
change, which in all severe cases is manifested by the appearance of the 
skin, and in other ways. 

Cerebro-spinal fever differs widely in many ])articulars from typhus, al- 
though it is probable that it was confounded with it previously to the pres- 
ent century, and many even now consider it a form of that disease. Their 
theory is, that from some unknown cause or influence the poison of the con- 
stitutional disease acquires for the time an affinity for the great nervous 
centres, producing their congestion and inflaramation,justas that of scarlet 
fever causes a pharyngitis, and if we could detach from it these local mani- 
festations, we would have a malady which differs but little, if at all, in its 
clinical history and nature, from typhus. 

The following are some of the differences which, in my opinion, not only 
establish the non-identity of these two fevers, but show that there is no 
close relationship between them. The causes of typhus are determined. 
Crowding, personal uncleanliness, and imperfect ventilation are sufficient 
to produce it in any season or climate. Such is not the case with cerebro- 
spinal fever. The most that can be said of the agency of these and simi- 
lar anti-hygienic conditions in causing this fever is, as we have already 
stated, that they produce deterioration in the tone of the system, so that 
it is less capable of resisting the prevailing epidemic influence. The cause 
of cerebro-spinal fever occurs independently of the usual conditions of life 
and is present or operative only at long intervals ; else the epidemic would 
not be so rare. Typhus is highly contagious; cerebro-spinal fever is not 
contagious, or is feebly so. Typhus is rare under the age of ten years, and 
is most frequent in youth and manhood, while the reverse is true of cerebro- 
spinal fever. Typhus commences with mild or moderately severe symp- 
toms, which increase in severity day by day, and the period of greatest 
danger is therefore at an advanced stage of the disease. Contrast this with 
the violence of the initial symptoms of cerebro-spinal fever, and the fact 
that the first and second days are most perilous. Moreover, typhus does 
not seem to be more prevalent during epidemics of cerebro-spinal fever, 
than at other times. 

If we pass over those many symptoms due to lesions of the cerebro-spinal 
axis, which are present in cerebro-spinal fever, but are absent in typhus 
fever, there are other points of dissimilarity which cannot be satisfactorily 
explained, except on the supposition of an essential difference in the two 
diseases. The sordes on the teeth and gums, dry and brown fur upon the 
tongue, peculiar mouse-like odor, and more definite duration of typhus, are 



PROGNOSIS. 295 

points of contrast with cerebro-spinal fever. Moreover, and as, in iny mind, 
very conclusive evidence of the non-identity of typhus and cerebro-spinal 
fever, that common lesion of the former, namely, enlargement and soften- 
ing of the spleen, is seldom present in the latter. The spleen has usually 
been found normal or moderately congested in most post-mortem exami- . 
nations of cerebro-spinal fever. 

Where, therefore, should cerebro-spinal fever be placed in the catalogue 
of diseases ? It resembles scarlet fever in the suddenness and violence of 
its onset; sporadic meningitis on the one hand, and typhus on the other, 
as we have seen, in many of its symptoms; influenza and cholera, in the 
infrequency of its visitations, and its pandemic nature. But the particu- 
lars in which it differs from these diseases are more numerous and important 
than those in which it resembles them. Like a rare object in nature, which 
naturalists are not able to classify with others on account of dissimilarities, 
though it has its resemblances to more than one, cerebro-spinal fever ap- 
pears to stand alone, as a peculiar constitutional disease, having a peculiar 
but obscure cause, and a dangerous manifestation or expression located in 
the cerebro-spinal system. 

Prognosis. — Cerebro-spinal fever is justly one of the most dreaded of 
the epidemic diseases, on account of the great mortality which attends it, 
and the fact that those who survive are often left with some incurable ail- 
ment. The following are the statistics of fifty-two cases, most of which 
occurred in my own practice, and the rest I visited in consultation ; twenty- 
six were cured and twenty-six died. Sixteen of the twenty-six who died 
were profoundly and hojDelessly comatose within the first seven days, most 
of them dying within that time, and some even on the first and second 
days, while others lingered into the second week and died without any 
sign of returning consciousness. These statistics therefore show, and the 
same is true of the statistics of other observers, that the first week is the 
time of greatest danger, and if no fatal symptoms are developed during 
this week recovery is probable. Only three deaths occurred after the 
twenty-first day, one from purpura hsemorrhagica, the haemorrhages taking 
place from the mucous surfaces, and the other two after a sickness of more 
than two months, in a state of extreme emaciation and prostration. In 
these last cases muscular tremors and convulsions preceded death. The 
ten who subsequently died, but did not become comatose during the first 
week, were nevertheless seriously sick from the first day, but there was hope 
and some expectation of a different issue till near death. 

There is probably no disease which falsifies the predictions of the physi- 
cian more frequently than this. This is due partly to the severity of the 
cerebral symptoms in the commencement, which, did they occur in the 
common forms of meningitis, with which he is more familiar, would justify 
an unfavorable prognosis, and partly to t*he remissions and exacerbations, 
the occurrence alternately of symptoms of apparent convalescence and 



296 CEREBKO-SPINAL FEVER. 

recrudescence, or relapse, which characterizes the course of this disease. 
Grave initial symptoms, which might seem to have a fatal augury, are 
often followed by such a remission, that all danger seems past, and in a 
few hours later pei'haps the symptoms are nearly or quite as grave as at 
.first. 

Under the age of five years, and over that of thirty, the prognosis is less 
favorable than between these ages. An abrupt and violent commencement, 
profound stupor, convulsions, active delirium, and great elevation of tem- 
perature are symptoms which should excite solicitude, and render the prog- 
nosis guarded. If the temperature remain above 105'' death is probable, 
even with moderate stupor. Numerous and large petechial eruptions show 
a profoundly altered state of the blood, and are therefore a bad prognostic, 
and so is continued albuminuria, as it indicates great congestion of the kid- 
neys, associated probably with other internal congestions. In one case, a 
boy, which I had an opportunity of examining nearly a year after the at- 
tack, the kidneys were still affected. There was anasarca of the face and 
extremities with albuminuria. The renal congestion had apparently de- 
generated into a chronic Bright's disease. The result of the case 1 have 
not ascertained. Profound stupor, though a dangerous symptom, is not 
necessarily fatal as long as the patient can be aroused to partial conscious- 
ness, and the pupils are responsive to light. So long as it does not pass 
into actual coma, it is less dangerous than active or maniacal delirium, 
which is apt to eventuate in this coma. 

A mild commencement, with general mildness of symptoms, as the ability 
to comprehend and answer questions, moderate pain and muscuhir rigidity, 
some appetite, moderate emaciation, little vomiting, etc., justifies a favor- 
able prognosis, but even in such cases it should be guarded till convales- 
cence is fully established. 

Death in the first stages of cerebro-spinal fever appears to occur ordi- 
narily from coma, but we will see from the lesions that congestion of the 
posterior portions of the lungs is frequent, and Sanderson says : 

" In all the fatal cases which came under my notice, the most prominent 
symptoms, which preceded death, were those which indicate impairment 
and perversion of the respiratory functions. As the breathing became more 
hurried and difficult, the general depression became more intense, the 
pulse became weaker and quicker, and the temperature of the skin more 
elevated." 

He cites the case of a child, who died in that way, but was at the same 
time comatose. In more protracted cases in which there is softening of 
portions of the cerebro-spinal axis, or fibrino-purulent collections around 
it, which are not absorbed, death may occur either from convulsions and 
coma or from exhaustion. We have already alluded to one case in which 
purpura hsemorrhagica was developed and the child was exhausted by the 
haemorrhages. 



ANATOMICAL CHARACTERS. 297 

Those who fully recover often exhibit symptoms usually of a nervous 
character, as irritability of disposition, headaches, etc., for mouths after 
convalescence is established. 

Diagnosis. — Cerebro-spinal fever, on account of the nature and severity 
of its symptoms and the suddenness of its onset, may be mistaken for scar- 
latina, and viee versa. In one instance, to my knowledge, this mistake was 
made. High febrile movement, vomiting, convulsions, and stupor, are 
common in the commencement of scarlet fever, and we have seen that the 
same symptoms ordinarily usher in the severer forms of cerebro-spinal 
fever. It w'ill aid in diagnosis to ascertain whether there is redness of the 
fauces, for this is present in the commencement of scarlet fever, and in a 
few hours later the characteristic efflorescence appears upon the skin. 

The diagnosis of cerebro-spinal fever from the common forms of menin- 
gitis is ordinarily not difficult, for while in the former there is the maximum 
intensity of symptoms on the first day, in the latter there is a gradual and 
progressive increase of symptoms from a comparatively mild commence- 
ment. Moreover cases of ordinary or sporadic meningitis occurring at the 
age when cerebro-spinal fever is most frequent, are commonly secondary, 
being due to tubercles, caries of the petrous portion of the temporal bone, 
or other lesion, and there are therefore in these cases preceding and accom- 
panying symptoms, which are directly referable to the antecedent disease. 
We have seen how different the case is with cerebro-spinal fever, which in 
most patients begins abruptly in a state of previous good health. Again 
in cerebro-spinal fever, after the second or third day, hypersesthesia, re- 
traction of the head, and other characteristic symptoms occur, which are 
either not present, or are much less pronounced, in ordinary meningitis. 
The symptoms of hysteria sometimes bear a close resemblance to the de- 
lirium observed in certain cases of cerebro-spinal fever. But the thermom- 
eter enables us to make the diagnosis, for in h3'steria there is no febrile 
movement. In our remarks on the nature of cerebro-spinal fever we have 
sufficiently described the differences between this disease and typhus. 

Anatomical Characters. — I have notes of the post-mortem appear- 
ances in 76 cases, published chiefly in British and American journals ; 29 
died within the first three days ; 28 between the third and twenty-first day ; 
8 died after the twenty-first day, and the duration of the remaining 11 was 
unknown. These records furnish the data for the following remarks: 

The blood undergoes changes, which are due in part to the inflamma- 
tory, and in part to the constitutional and asthenic, nature of the disease. 
The proportion of fibrin is increased in cases that are not speedily fatal, 
as it ordinarily is in idiopathic inflammations. Analyses of the blood, 
published by Ames, Tourdes, and Maillot, show a variable proportion of 
fibrin from 3.40 to more than six parts in 1000. In sthenic cases accom- 
panied by a pretty general meningitis, cerebral and spinal, there is, after 
the fever has continued some days, the maximum amount of fibrin, while 



298 CEREBRO-SPINAL FEVER. 

ill the asthenic and suddenly fatal cases, with inflammation slight, or in 
its commencement, the fibrin is but little increased. The most common 
abnormal appearance of the blood observed at autopsies is a dark color 
with unusual fluidity, and the presence of dark, soft clots. Exceptionally 
bubbles of gas have been observed in the large vessels and the cavities of 
the heart. An unusually dark appearance of the blood, small and soft 
dark clots, and the presence of gas bubbles, when only a few hours have 
elapsed after death, indicate a malignant form of the disease, in which 
this fluid is early and profoundly altered. In certain cases the blood is 
not so changed as to attract attention from its appearance. The points or 
patches of extravasated blood which are observed in the skin during life 
in a certain proportion of cases, usually remain in the cadaver. In incising 
them the blood is seen to have been extravasated, not only in the layers 
of the skin, but also in the subcutaneous connective tissue. Extravasa- 
tions of small extent are also sometimes observed upon the thoracic and 
abdominal organs. 

In those who die after a sickness of a few hours or days, namely, in the 
stage of acute inflammatory congestion, the cranial sinuses are found 
engorged with blood, and containing soft, dark clots. The meninges en- 
veloping the brain are also intensely hypersemic in their entire extent in 
most cadavers; but in some, in certain parts only, while other portions 
appear nearly normal. In those cases which end fatally within a few 
hours, this hypersemia is ordinarily the only lesion of the meninges ; but 
if the case is more protracted, serum and fibrin are soon exuded from the 
vessels into the meshes of the pia mater, and underneath this membrane 
over the surface of the brain. Pus-cells also occur mixed with the fibrin, 
sometimes so few as to be discovered only by the microscope, but in other 
cases in such quantity as to be much in excess of the fibrin, and be readily 
detected by the naked eye. Pus, which in these cases, no doubt, consists 
of white blood-corpuscles which have escaped with the fibrin from the 
meningeal vessels, sometimes appears early in the disease. Thus, in the 
Dublin Quarterly Journal, 1866, Dr. Gordon relates the history of a case 
in which death occurred after a sickness of five hours, and a purulent- 
appearing greenish exudation had already occurred in places under the 
meninges. The exudation of fibrin commences also in the course of a few 
hours. Thus in a case of thirty hours' duration, published by Dr. William 
Frothingham in the American Medical Times, April 30th, 1864, and in 
another of one day's duration, published by Dr. Haverty in the Dublin 
Quarterly Journal for 1867, exudation of fibrin had already occurred in 
and under the pia mater. The arachnoid soon loses its transparency and 
polish, and presents a cloudy appearance over a greater or less extent of 
its surface. This cloudiness is greatest in the vicinity of the fibrinous exu- 
dation, but it occurs also where no such exudation is apparent to the naked 
eye. Dr. Gordon describes a case of only eight hours' duration, in which 



ANATOMICAL CHAEACTERS. 299 

the arachnoid was already opaque at the vertex, but of normal appearance 
at the base of the brain {Dublin Quarterly Journal, 1866), though the 
vessels of the pia mater were everywhere greatly congested. 

The exudation, serous, filjrinous, and purulent, occurs, as in other forms 
of meningitis, within the meshes of the pia mater, and underneath this 
membrane over the surface of the brain. The fibrin is raised from the sur- 
face of the brain with the meninges. It is most abundant in the inter- 
gyral spaces around the course of the vessels, over and around the optic 
commissure, the pons Varolii, the cerebellum, medulla oblongata, and along 
the Sylvian fissures. It is most abundant in the depressions, where it 
sometimes has the thickness of yV ^^ 4 ^^ ^^ inch, but it often extends 
over the convolutions so as to conceal them from view. 

Most other forms of meningitis have a local cause, and are therefore 
limited to a small extent of the meninges, as for example meningitis from 
tubercles, or caries of the petrous portion of the temporal bone, in both 
which it is commonly limited to the base of the brain, or from accidents 
when the meningitis commonly occurs upon the side or summit of the brain. 
The meningitis of cerebro-spinal fever, on the other hand, having a gen- 
eral or constitutional cause, occurs with nearly equal frequency upon all 
parts of the meningeal surface, except that it is, perhaps, most severe in 
the depressions where the vascular supply is greatest. In cases of great 
severity, the inflammatory exudation, fibrinous, or purulent, or both, may 
cover nearly, or quite, the entire surface of the brain. Thus, in the case 
of a negro, 35 years old, only four days sick, whose body was examined at 
Bellevue Hospital on May 30th, 1872, the record states that there was a 
purulent exudation over the entire surface of the cerebrum and cerebellum. 
The quantity of serous exudation varies according to the duration and 
amount of congestion. In some the quantity is so small as scarcely to attract 
attention, but in other instances, especially when the disease is protracted, 
it is large. In a case reported by Dr. Moorman in the Amer. Jour, of 
Med. Sci. for Oct. 1866, it is stated that about three pints of turbid serum 
escaped from the cranial cavity in attempting to remove the brain, but as 
there was no measurement the statement may be somewhat exaggerated. 

In those who die at an early stage of the disease, the vessels of the brain, 
like those of the meninges, are hypersemic, so that numerous "puncta vas- 
culosa" appear upon its incised surface. At a later period the hypera3raia, 
like that of the meninges, may disappear. If there is much efflision of 
serum within the ventricles and over the surface of the brain, the convo- 
lutions are apt to be flattened, and the pressure may be such that the 
amount of blood circulating within the brain is reduced below the normal 
quantity. Thus, in the case of a child of three years, who lived sixteen 
days, and was examined after death by Burdon-Sanderson, the ventricles 
contained a large amount of turbid serum, and the brain-substance Avas 
everywhere pale and anajmic. ' 



300 CEREBRO-SPINAL FEVER. 

Cerebral ramollissement occurs in certain eases. At one of the examina- 
tions in Charity Hospital, the patient having been only three days sick, 
the brain was found much softened. The dissection was made seven hours 
after death, so that the softening could not hav.e been the result of decom- 
position. At one of the post-mortem examinations in Bellevue Hospital, 
softening of the fornix, corpus callosuni, and septum lucidum was observed ; 
and in another, softening in the neighborhood of the subarachnoid space. 
In a case related by Dr. Moorman in the Amer. Jour, of Med. Sci. for 
Oct. 1866, it is stated that portions of the brain, medulla oblongata, 
and pons Varolii were softened. In a case observed by Dr. Upham, 
there was softening of the superior portion of the left cerebral hemis- 
phere. Occasionally the whole brain is somewhat softened. Burdon-San- 
derson, Russell, and Githens, each relate such a case. Moreover, the walls 
of the lateral ventricles are oi'dinarily more or less softened in these cases, 
as in the ordinary form of meningitis. In rare instances the brain is oedem- 
atous, as in a case published by Dr. Hutchinson in the Amer. Jour, of 
Med. Sci. for July, 1866. In this case the patient was only four days sick, 
and the whole brain was oedematous, serum escaping from its incised sur- 
face. 

The ventricles contain liquid, in some patients transparent serum, in 
others serum turbid and containing flocculi of fibrin or fibrin with pus. 
The liquid in the different ventricles as they intercommunicate is similar. 
The choroid plexus is either injected or it is infiltrated with fibrin and pus. 
In advanced cases with the abatement of the inflammation absorption 
commences. The serum obviously disappears soonest and the pus and 
fibrin more slowly, by fatty degeneration and liquefaction. Still absorp- 
tion and the return of the brain and meninges to their normal state are 
slow, and hence the tediousness of convalescence. An infant, whom I 
was allowed to examine in the practice of another physician, took the dis- 
ease at the age of five months, and two months subsequently, great promi- 
nence of the anterior fontauelle and other symptoms indicated still the 
presence of a considerable amount of effusion within the cranium. No 
post-mortem examinations, so far as I am aware, have yet revealed the 
state of the brain and meninges in those who have had this disease at 
some forrae'r period and entirely recovered from it, but it is not improba- 
ble that some opacity and preternatural adhesions in places may continue 
for life. 

The remarks made in reference to the cerebral, apply for the most part 
to the spinal meninges. There is at first intense hyperemia of the mem- 
branes usually over the entire surface of the cord, soon followed by fibrin- 
ous, purulent and serous exudation, in the meshes of the pia mater, and 
underneath this membrane. Thickening and opacity of the meninges, and 
often adhesions, occur in protracted cases. The exudation is sometimes 



TREATMENT. 301 

confined to a portion of the meninges, more frequently that covering the 
posterior than anterior aspect of the cord, but it may occur in any part, 
and in severe cases the entire pia mater of the spine is infiltrated with it. 
The exudation may have the usual appearance of fibrin and pus, but it is 
sometimes greenish and sometimes bloodstained. Small extravasations 
of blood almost necessarily occur as a result of the intense hypera^mia, 
and in one case related by Burdon-Sanderson it is stated that there was 
a layer of blood ^ of an inch thick over the whole cord below the bron- 
chial swelling. In post-mortem examinations the central canal of the 
cord has usually been overlooked. Ziemssen relates a case, and Gordon 
another, in which it was dilated and filled with purulent fluid. The ana- 
tomical changes which have been observed in the cord itself have been in- 
jection of its vessels in recent cases, and occasional softening of portions. 
Thus, in a case which was examined in Bellevue Hospital April 13th, 1872, 
it is stated that there was softening of the cord in the upper part of the 
dorsal region. In most of the examinations the only abnormal appear- 
ance observed in the cord was bypersemia, but in a considerable propor- 
tion of cases the records state that the substance of the cord appeared 
normal. 

No constant or uniform lesions occur in the organs of the trunk. The 
most common is congestion of the lungs, especially of the posterior por- 
tions, with more or less oedema, and nodules of hepatization or points of 
extravasation. Effusion of serum, sometimes bloodstained, occasionally 
occurs in the pleural and other serous cavities. The auricles and ventri- 
cles of the heart, as already stated, contain more or less blood, with soft 
dark clots in the more malignant and rapidly fatal cases, but larger and 
firmer in those which have been more protracted. The spleen, liver, kid- 
neys, stomach and intestines, one or more, are sometimes congested, but 
in other cases their appearance is normal. The absence of uniformity as 
regards the state of the spleen, the fact that in many patients it undergoes 
no appreciable change, is important, since this organ is so generally en- 
larged and softened in infectious diseases. The agminate and solitary 
glands have ordinarily been overlooked at post-mortem examinations, but 
in certain cases they have been found prominent. 

Treatmekt. — Preventive. — Although we do not fully understand the 
conditions in which cerebro-spinal fever originates, it is certain, from facts 
observed in epidemics, that we are able to do something to diminish its 
severity and prevalence and to protect the community. Measures to this 
end must be of a twofold character, namely, such, in the first place, as are 
calculated to improve the suiToundings of the individual, so as to conduce 
to a better state of health, and secondly, the regulation of his mode of 
life. Cleanliness and dryness of streets and domiciles, perfect drainage 
and sewerage, prompt removal of all refuse matter, avoidance of over- 
crowding, so as to procure the utmost salubrity in the atmosphere, the use 



302 CEREBRO-SPIXAL FEVER. 

of plain and wholesome food — in a word, the sti-ict observance of sanitary 
requirements in all the surroundings — cannot fail to reduce the number 
and diminish the severity of cases; for, as we have seen, this disease as- 
sumes its worst form and numbers the most victims where anti-hygienic 
conditions most abound. Of scarcely less importance is a strict surveil- 
lance of the mode of life, especially of children and young people, during 
the time of an epidemic. We have seen that this disease not infrequently 
follows irregularities in the mode of life, excesses of whatever kind, and 
fatigue, mental or bodily. These should therefore be avoided. A quiet 
mode of life and moderate exercise, plain and wholesome and regular 
meals, and the full amount of sleep, afford some, but not complete, security 
in the midst of an epidemic. 

Curative. — It will aid in determining the proper mode of treatment to 
bear in mind the anatomical characters as ascertained by post-mortem ex- 
aminations. As the chief danger in the first days is from the intense in- 
flammatory congestion of the cerebi'o-spinal axis, the prompt employment 
of measures calculated to relieve this is of the utmost importance. To 
this end bladders or bags of ice should be immediately applied over the 
head and nucha, and constantly retained there during the first week. 
Bran mixed with pounded ice produces a more uniform coldness, and is 
more comfortable to the patient, than ice alone. Cold produces a prompt 
and powerful effect in diminishing the turgescence of the cerebral and 
meningeal vessels. A hot mustard foot-bath or general warm bath with 
mustard, should also be employed as early as possible, since it acts so 
powerfully as a derivative from the hypersemic nerve-centres, tends to calm 
the nervous excitement and prevent convulsions. An enema to open the 
bowels is also proper. 

Should bloodletting be emplo^-ed, especially in the more sthenic cases? 
Even in the commencement of the present century, when it was customary 
to bleed generally or locally in the treatment of inflammatory and febrile 
diseases, a majority of the American practitioners whose writings are ex- 
tant discountenanced the use of such measures in the treatment of this 
disease. Drs. Strong, Foot, and Miner, though under the influence of the 
Broussaian doctrine, were good observers, and they soon abandoned the 
use of the lancet and leeches in the treatment of these patients for more 
sustaining measures. Strong, who published a paper on spotted fever in 
the Medical and Philosojjhical Register, in 1811, states that certain phy- 
sicians employed venesection as a means of relieving the internal conges- 
tions, but, finding that the pulse became more frequent after a moderate 
loss of blood, they soon laid aside the lancet. Some experienced phy- 
sicians of that period, however, continued to recommend and practice de- 
pletion, general as well as local, as, for example. Dr. Gallop, who treated 
many cases in Vermont in the epidemic of 1811. 

No physician at the present time recommends venesection, but some of 



TREATMENT. 303 

the best authorities, as Sanderson and Nienieyer, approve of local bleed- 
ing in certain caaes. It may be stated, as a safe rule, that leeches or other 
modes of local depletion should not be prescribed in a large majority of 
cases, and if prescribed in any case it should be on the first day, for on 
the first day the maximum of inflammatory congestion is attained, and in 
no case should more than a very moderate quantity of blood be abstracted. 
Blood should only, in ray opinion, be abstracted, and in small quantity, 
from the temples or behind the ears, in the more sthenic cases, in which, 
after the prompt employment of the other measures recommended, the 
stupor becomes more and more profound, and the patient appears already 
in incipient coma. But in allowing a moderate depletion it must not be 
forgotten that the disease is in its nature asthenic, and in its subsequent 
course will require sustaining measures. It is apparent, however, that the 
abstraction of blood, if once allowed, is likely to be recommended too fre- 
quently in the treatment of this disease by those who have had but little 
experience with it, for the state of most patients in the commencement 
seems so critical, and the stupor so great, that the most energetic measures 
seem to be required. But if the blood of patients is spared, and they are 
promptly and properly treated otherwise, it is surprising to see how many 
emerge from the stupor and finally recover. For example, in a case re- 
lated to me by Dr. Griswold, the patient seemed to be comatose for three 
days, being apparently unconscious and the pupils scarcely responding 
to light, but he recovered without losing blood. In only one case have I 
recommended the abstraction of blood, and this was so instructive that I 
will briefly relate it. 

M., a female, 4 years old, was seized at 2 a.m., March 7th, 1873, with 
vomiting, chilliness, and trembling, followed by severe general clonic con- 
vulsions lasting about fifteen minutes. On visiting her early in the morn- 
ing, I found her semi-comatose, with a pulse of 132, which in a few hours 
rose to 156; temperature 101^"^, respiration 44; eyes closed; pupils mode- 
rately dilated and responding feebly to light; surface presenting a dusky 
mottling ; constant tremulousness, and frequent twitching of limbs. Four 
grains of bromide of potassium were ordered to be given every hour to 
two hours, with tiie usual local measures, namely, ice to the head and 
nucha, and a hot mustard foot-bath, followed by sinapisms to the extrem- 
ities. 

8^^. Pulse 136 ; is partly conscious when aroused, but immediately re- 
lapses into sleep ; head considerably retracted ; bowels constipated ; vomits 
occasionally ; temperature 102^. Treatment, a leech to each temple, on 
account of the extreme stupor ; other treatment to be continued. 

9th. The leech-bites bled, though slowly, nearly five hours; pulse 180, 
and so feeble as to be counted with difficulty ; temperature 101-j°. The 
patient is evidently sinking. Treatment, a teaspoonful of Bourbon whisky 
in milk every two hours, beef tea and other nutritious drinks frequently, 
also the bromide at intervals. Evening, pulse, 172, still feeble. 

10th. Pulse 180, barely perceptible; great hyperiesthesia ; temperature 



304 CEREBRO-SPINAL FEVER. 

of axilla 100^, of fingers and hand below 90^ ; axes of eyes directed 
downwards. 

llth. Pulse still very feeble, varying from 160 to 228; temperature 
1025°. There has been no intermission in the use of the stimulants or 
nutriment night or day ; pupils moderately dilated and somewhat more 
sensitive to light. 

After this the patient gradually rallied for a time, so that the pulse 
became stronger and less frequent, but death finally occurred after nine 
weeks in a state of emaciation and extreme exhaustion. Slight convul- 
sions occurred in the last hours. 

It is seen that, after the loss of blood from two leech-bites, this patient 
passed into a state of extreme exhaustion so that for three days I did not 
believe that she would live from one hour to another, and death finally 
occurred. Although the loss of blood may have been useful in relieving 
the stupor, yet a worse danger resulted. Experience like this, which I 
believe corresponds with that of other observers, shows how seldom and 
with what caution the blood of the patient should be abstracted. 

The internal remedy most in favor with the profession of this city, and 
justly, in the first stage of this disease, is the bromide of potassium, especi- 
ally in the treatment of children. Evidently a remedy is required w'hich 
will diminish the calibre of the arterioles, and consequently the hyper- 
emia of the cerebro-spinal axis and its meningeal covering. Ergot has 
been employed for this purpose, and in some instances with a satisfactory 
result ; but bromide of potassium, while it contracts the arterioles of the 
encephalon, is at the same time a powerful sedative to the nervous system. 
More than any other safe internal remedy, it prevents convulsions in chil- 
dren, which occurring in this disease add a passive to the already intense 
active congestion of the cerebro-spinal axis. This agent in medicinal 
doses produces no ill effect except when given frequently for a lengthened 
period, when it may accumulate in the system. A child of five years may 
take five or six grains every two, three, or four hours, according to the 
urgency of the case. After the first week it should be given less frequently, 
and finally omitted. The practice of some physicians, of continuing the 
use of the bromide in frequent large doses after the first or at least second 
week, is to be deprecated, for after a time it is apt to produce symptoms 
which can with difficulty be discriminated from those of cerebro-spinal 
fever. These are stated as follows by Mr. Wood : " Great muscular de- 
bility, dimness of sight with dilated pupils, irregular gait, the patient 
reeling as though intoxicated, whilst nausea, vomiting, or purgation, with 
abdominal pain of a dull aching character, may also be present." {British 
Med. Jour., October 14th, 1872.) It is obviously better after the first 
week, if the symptoms are no longer urgent, to discontinue the bromide 
entirely, than to continue its use in such doses and for such a period that 
there may be danger of producing its physiological effects. Nevertheless 



TREATMENT. 305 

it is proper to resume its use during its periods of recrudescence whicli are 
so apt to occur at any stage of tlie disease. 

Tlie bromide cannot be depended on to allay the pain, which often, on 
account of its severity, requires immediate treatment, and sometimes it 
does not allay the excessive agitation. For these symptoms an opiate is 
indicated, which in my practice has produced a much more satisfactory 
result than hydrate of chloral. Quite moderate doses are sufficient to pro- 
duce the effect desired. A patient of six years was quieted by 3^3 part of 
a grain of sulphate of morphia. So useful are opiates in allaying pain in 
this disease, that some observers, as Niemeyer and Ziemssen, consider them 
the most, valuable of the internal remedial agents which we possess, and 
the benefit from their use in these cases has certainly had considerable 
effect in disabusing the minds of physicians of the dread which they have 
entertained of their employment in acute affections of the brain. Mann- 
koff" and others have employed subcutaneous injections of morphia. 

Quinia is suggested as a remedy by the paroxysmal character of the 
pains and the fever, but I believe that I am sustained by the general ex- 
perience of physicians in this city in stating that it has very little effect 
upon either of these symptoms, or upon the course of the disease. I have 
employed it in small and large doses, as many as fifteen grains per day to 
a child of thirteen years, but am not aware that it has been of any service 
except as a tonic. There is perhaps no better remedy for the nausea than 
bismuth in large doses. 

Frequent counter-irritation along the spine by dry cups or an irritating 
liniment is useful from the first, and vesication of the nucha by canthar- 
idal collodion or otherwise when the ice-bag is discontinued. Sustaining 
measures should also be commenced early. Tonics, vegetable and ferru- 
ginous, should be administered after the disease has continued a few days, 
alternating with and finally superseding the bromide. I have in some 
cases employed the citrate of iron and ammonia. The diet must be nutri- 
tious, consisting of the meat broths, milk, etc., during the entire course of 
the disease. Most patients require alcoholic stimulants sooner or later. 
In cases presenting a feeble pulse, and other evidences of prostration, their 
early and continued employment is advisable, as in the case which I have 
related, in which whisky was administered every two hours after the 
second day. The constipation is ordinarily best relieved by enemata. The 
room should be dark, of comfortable temperature, and quiet. 



20 



306 ACUTE RHEUMATISM. 



CHAPTER V. 



ACUTE RHEUMATISM. 



Rheumatism is a constitutional disease with a local manifestation, 
namely, an inflammation of the sero-fibrous tissues, chiefly in and around 
the articulations, but occasionally in other parts. It is less frequent prior 
to puberty than in the years succeeding it ; still, it is not uncommon in 
children after the fifth year. Under this age it is comparatively rare, but 
is, probably, not so infrequent as is commonly supposed. For while in the 
adult the diagnosis of rheumatism is easy, in children this disease is likely 
to be overlooked, if, as is true in a large proportion of cases in early life, 
the swelling and redness of the affected joints are slight, and only a few 
joints are inflamed. If there is cardiac inflammation, the articular affec- 
tion may be nearly absent, thus rendering the diagnosis more obscure. 
That rheumatism is not so very rare under the age of five years, I infer 
from the fact that we now and then meet with cases of valvular disease in 
children of this age or older, which, there can be little doubt, had its origin 
in rheumatism, although the parents are not aware that there has ever 
been an attack of this disease. Such cases have not infrequently been 
brought to the children's class in the Outdoor Department at Belle vue. 
Thus, in January, 1871, a little girl, three years old, was presented, hav- 
ing distinct aortic direct, and mitral regurgitant murmurs. The mother 
was not aware that she had had rheumatism, but at the age of twenty 
months she had for several days pretty active febrile symptoms, which the 
physician attributed to disease of the lungs. In April, 1871, another girl, 
of the same age, was brought to the clinique, having a distinct mitral 
regurgitant murmur. The mother stated that she had been well till a 
month previously, when she was confined to her bed for a few days, hav- 
ing a high fever. She was attended by a homoeopathic physician, and the 
exact character of her sickness the mother was not able to state. Further 
medical advice was sought, as the child remained delicate, though her 
health was better than at first. There can be little doubt that the obscure 
fever in this case had been rheumatic. In another child treated elsewhere, 
not old enough to i-elate the subjective symptoms, there was, in addition 
to an intense fever, evident pain in one foot or leg, when the limb was 
moved. Still, the nature of the disease was not diagnosticated till some 
time after recovery, when a valvular murmur was accidentally discovered. 



CAUSES SYMPTOMS. 307 

Such histories, which I do not think are rare, show, if my opinion of them 
is correct, that rheumatism may occur not very rarely in young children, 
even infants, for which purpose they are here introduced, but they incul- 
cate the important practical lesson, that the disease at this age may be so 
obscure, or latent, as to be overlooked even by good diagnosticians. 

Some observers, meeting cases of valvular disease in children, without 
the history of rheumatism, have concluded that rheumatism is not the 
chief cause of endocarditis at this age (Dr. A. StefFen, Jahrbuchfur Kinderk., 
1870) ; but the explanation which I have given seems to me more in con- 
sonance with the facts. Scarlet fever not infrequently causes endocarditis, 
but this exanthem is not apt to occur without detection, and it has been as 
often absent as has rheumatism from the histories as given by the parents 
of young children with valvular disease, whom I have examined. More- 
over, the endocarditis of scarlet fever is in many cases the result of scar- 
latinous rheumatism. 

Rheumatism in children is primary or secondary. The secondary form 
occurs chiefly in the declining stage of scarlet fever and variola. It is 
stated, also, to occur occasionally in new-born infants during epidemics of 
puerperal fevei\ I have not observed such cases. 

Causes. — The important cause of rheumatism is a predisposition, which, 
in a large proportion of cases, is inherited. Hence the fact that it is apt 
to occur in different members of the same family. When the family his- 
tory shows a strong predisposition to rheumatism, it occurs in the child 
from a slight exciting cause ; if no such predisposition exists, it only oc- 
curs through unusual circumstances of exposure. The ordinary exciting 
cause is the same as in most idiopathic inflammations, namely, exposure 
to cold ; but a strong rheumatic diathesis appears to be sufficient in itself 
to produce an outbreak of the disease. Children who have had one attack 
are especially liable to another. 

Symptoms. — The commencement of acute idiopathic rheumatism is in 
most cases sudden ; occasionally fever, and a degree of soreness or stiffness, 
precede the articular affection for a few hours or days. The inflammation, 
slight at first, increases gradually, attaining its maximum intensity within 
one or two days. The joint is painful, red, hot, and swollen. The swell- 
ing is due to inflammatory oedema of the tissues surrounding the joint and 
effusion within the joint. As in all inflammations, the vascularity of the 
parts involved is increased, the synovial membrane loses more or less its 
lustre, and the effused fluid, which is mainly serum, has been found, in 
most of the cases in which an opportunity was presented to examine it, to 
contain, like the pleuritic exudation, a few globules of pus. Rarely, in a 
reduced state of the system, so much pus is produced within the joint as 
to constitute a true abscess, and rarely also fibrin is exuded, producing a 
rubbing sensation when the joint is moved, and endangering permanent 



308 ACUTE RHEUMATISM. 

adhesion of the articular surfaces. Fortunately, however, in the vast 
majority of cases, tlie substance exuded both without and within the joint 
is mainly serum, and therefore the rapid subsidence of the swelling when 
the inflammation ceases. The pain is commonly not severe when the child 
is quiet, but it is greatly increased if the joint is pressed or the limb 
moved. 

The joints of the extremities are most frequently the seat of rheumatic 
inflammation, but occasionally those of the trunk, as the intervertebral, 
the symphysis pubis, etc., are involved. As the inflammation abates in 
the articulations first aflfected it reappears in others, unless the materies 
morbi has been eliminated from the system. It is seldom that more than 
two or three of the joints are in a state of active inflammation at the same 
time. 

The temperature in acute rheumatism is elevated two or three degrees 
above that of health, and the pulse varies from 120 to 140, its frequency 
depending on the age of the patient, as well as the gravity of the disease. 
Perspiration is a common symptom. The appetite is impaired, the tongue 
slightly coated, and the bowels constipated. The watery element in the 
urine is diminished, as in most febrile diseases. There is no corresponding 
reduction in the solid elements, so that the urine is rendered more dense, 
and its specific gravity is high. The amount of urea and coloring matter 
excreted from the kidneys is augmented during the active period of rheu- 
matism, and the urine, when it cools, deposits urates. In ordinary cases 
there is no pi'omineut symptom referable to the nervous system, with the 
exception of the pain in the aflected joint. 

Acute rheumatism, if only the articulations were involved, would be a 
disease of little danger, however painful, but unfortunately, in its prone- 
uess to produce specific inflammation of the sero-fibrous tissues, the heart 
frequently becomes involved, less frequently the lungs and pleura, and in 
rare instances the cerebral or spinal meninges. Endocarditis is the most 
frequent of the heart inflammations occurring in rheumatism ; pericarditis, 
though less common, is not infrequent, while in rare instances myocarditis 
occurs, usually associated with the other inflammations. Endocarditis is 
limited to the left side of the heart, and seldom continues long without 
engaging the valves, aortic or mitral, or both, causing their infiltration, 
fibroid degeneration, with consequent thickening, and sometimes adhesion. 
The valvular lesion thus produced is in most instances permanent, so im- 
pairing the action of the valves as to obstruct in greater or less degree the 
flow of blood through the orifice or allow its regurgitation. 

The mitral valve is moi'e frequently aflfected than the aortic, at least 
bruits produced by this lesion are more frequent in the mitral than aortic 
orifice, and when they are heard in both orifices they are commonly loudest 
in the mitral. This fact, noticed by different observers, I have repeatedly 
verified by observations in this city. 



DURATION PROGNOSIS. 309 

While the articular affection pertaius to the clinical history of rheuma- 
tism, the internal inflammation, whether of the heart, lungs, pleura, or 
meninges, though similar as regards its pathological character, is propsrly 
regarded as a complication. Acute rheumatism is so frequently compli- 
cated by one or the other of these affections, that any disproportionate 
severity in the general symptoms, as compared with the inflammation of 
the joints, or any sudden and unexpected increase in the symptoms, should 
always lead the physician to examine thoroughly the condition of those 
organs which are most frequently affected. 

Inflammatory complications occur, as a rule, during the active period 
of rheumatism, when the inflammation is passing from joint to joint. If 
the general symptoms begin to improve, and no new joints are involved, 
the liability to complications is greatly diminished. Secondary rheuma- 
tism, occurring in most instances in connection with certain eruptive fevers, 
especially scarlatina, commonly affects only a few joints, often only one or 
two, as the wrist, and, though painful, is attended by slight swelling and 
redness. 

Duration — Prognosis. — With proper treatment and without compli- 
cation the febrile action in a few days begins to abate, and the disease 
commonly terminates within two weeks. Its duration is ordinarily shorter 
than in rheumatism of the adult. Fluctuations, however, are liable to 
occur. The disease may appear to be abating, and the articular inflam- 
mations nearly cease, when they return for a time, often without new ex- 
posure and without appreciable cause. The prognosis, even when cardiac 
inflammation has supervened, is in most cases favorable, except so far as 
the lesion resulting from this inflammation is concerned, which being 
permanent may entail much subsequent suffering, and occasion death after 
months or years. Indeed, what is most to be dreaded in cases of acute 
rheumatism is valvular disease or pericardial adhesion with its remoter 
consequences, namely, hypertroj)hy of heart, congestion and oedema of the 
lungs, dropsies, etc. 

Secondary rheumatism occurring in scarlet fever is sometimes also com- 
plicated -with, or rather coexists with, cardiac inflammation, pleuritis, or 
pneumonitis, rendering the prognosis more unfavorable. 

In rare instances the acute symptoms of rheumatism abate, but the joints 
remain stiff" and more or less swollen, and painful when moved. The 
acute has lapsed into a subacute or chronic rheumatism. Such a case, 
represented in the accompanying figure, was brought to the children's class 
in the Outdoor Department at Bellevue Hospital, in February, 1871. E. 
H., female, 3^ years old, had intermittent fever from the age of nine to 
fifteen months. From this time she remained well till the age of two 
years, when she was taken with acute rheumatism, commencing in her 
ankles and extending to other joints. The knee and hip joints on both 
sides have only partially recovered their mobility, and both legs and both 



310 



ACUTE RHEUMATISM. 





thighs are permanently flexed, so that the gait is slow and unsteady. It 
is impossible to straighten either limb without causing great pain, and 
attempts to straighten the thigh produce the arch 
in the back very similar to that in coxalgia. 

Diagnosis. — This is not difficult in ordinary cases, 
if a proper examination is made. In the commence- 
ment, if the affection of the joints is slight, rheuma- 
tism might be mistaken for remittent, typhoid, one 
of the eruptive fevers, or meningitis ; but, on careful 
examination, tenderness will be observed of one or 
more of the articulations, and probably some swell- 
ing. This tenderness is readily distinguished from 
the hypersesthesia which is common in the first stage 
of the essential fevers, and which is observed when 
pressure is made upon the chest or abdomen as well 
as upon the limbs, and is more marked between the 
joints than in them. Any doubt which may at first 
exist, whether the patient may not have one of those 
diseases, is soon dispelled, since their clinical history 
presents notable diflferences from that of rheumatism. 
I have known scrofulous arthritis, or scrofulous 
ostitis near the joint, present so close a resemblance 
to acute rheumatism as to be at first mistaken for it. In one instance this 
inflammation commenced in three joints distant from each other, so that the 
diagnosis at first was difficult. But scrofulous inflammation as well as that 
from pyaemia can be diagnosticated from rheumatic disease of the joints, by 
its greater persistence, less induration and symmetry in the swelling, and 
by the history of the case. Chronic rheumatism may produce deformity 
similar to that from chronic scrofulous inflammation, as in the case detailed 
above, but the rheumatic history, number of joints affected, bilateral charac- 
ter of the inflammation, good general health, etc., are sufficient to establish 
a clear diagnosis. 

Treatment. — The theory of the pathology of a disease determines the 
mode of treatment. It is believed that rheumatism is due to an acid, prob- 
ably lactic, in the blood, and hence alkaline remedies are commonly em- 
ployed, with the apparent eflfect of diminishing the severity of the disease 
and shortening its duration. The tartrate of soda and potassa, acetate of 
potassa, and the bicarbonate of soda or potassa, may be given singly or 
combined, according to the condition of the patient. The following is a 
good formula for a previously healthy child of six or eight years : 
R. Potas. et sodie tart., ^ss. 
Potas. acetat., ^ij. 
Syr. limonum, 
Aquaj, aa .^iij. Misce. 
Dose, two teaspoon fu Is every two or three hours. 



TREATMENT. 311 

Sulphate of morphia, Dover's powder, or other opiate, is ordinarily re- 
quired in the evening to procure rest and prevent any undue purgative 
effect of the medicine. If there is considerable pain in the joints, one or 
two doses of the same should be given through the day. If there is a ten- 
dency to diarrhoea, or a state of debility, measures of a more sustaining 
nature are required. For such cases the bicarbonate of soda or potassa or 
liquor potassse is preferable to the other alkalies. 

In a few days, by the alkaline treatment, the urates cease to appear in 
the urine, and the disease begins to decline. There is now little danger 
that any complication will occur if the internal organs have so far escaped. 
I know no remedies so effectual in relieving not only rheumatic inflamma- 
tions of the joints, but the general muscular tenderness which occurs from 
taking cold, and which is often present in the commencement of rheuma- 
tism, as the Rochelle salts and acetate of potash. 

Daring the declining period of rheumatism and in convalescence qui- 
nine or some preparation of cinchona should be employed and the alkali 
given less frequently. This tonic does indeed appear to exert a beneficial 
effect on the course of rheumatism, and it is employed by some judicious 
and experienced physicians from the commencement, as the main remedy. 
Certainly, iu all cases of debility, it, or a similar medicine, should be 
early employed, unless contraindicated by some complication. 

If there is a high temperature and quick pulse, quinine administered 
in an occasional large dose will be found very useful. Three to five 
grains may be given to a child of five years. 

Rheumatism impoverishes the blood, and the patient often begins to 
present an anemic appearance, when he requires iron in addition to the 
vegetable tonic. The citrate of iron and quinine may then be employed. 

Secondary rheumatism requires sustaining treatment from the first. 
Such cases ordinarily do well without alkalies, and with the general sup- 
porting measures employed for the primary disease. 

Pneumonitis complicating rheumatism is best treated by moderate 
counter-irritation and emollient poultices, and the internal use of carbo- 
nate of ammonia ; or, if there is ansemia, carbonate of ammonia with 
citrate of iron and ammonia. The other internal inflammations which 
are liable to arise as complications require iodide of potassium in decided 
doses. In pericarditis or endocarditis, if, as is commonly the case, the 
movements of the heart are accelerated, quinia in large doses, the tincture 
of aconite root, or tincture of digitalis, is required to the extent of re- 
ducing the number of pulsations to near the normal frequency. A child 
of six years can take one drop of aconite, or three or four times the quan- 
tity of digitalis, to be repeated, if necessary, in three hours, till the re- 
quired reduction of the pulse is effected. Patients often experience relief, 
by the use of these agents, from the palpitation and dyspncx'a consequent 
upon the embarrassed movements of the heart. If the heart disease is 
extensive and pulse feeble the (juiniue is preferable. 



312 ERYSIPELAS. 

The patient should be kept quiet, in a room of uniform temperature, 
and not exposed to draughts of air. By such precaution the danger of 
complications is greatly diminished. Repellent applications, as cold or 
irritants, should not be applied to the joints, as long as the disease is 
acute, for they also increase the danger of complications. The affected 
joints should be enveloped in flannel or cotton, and the pain, if intense, 
may be diminished by applying flannel wrung out of warm water. If the 
disease becomes subacute or chronic, if the urates have disappeared from 
the urine, and the inflammation ceases to pass from joint to joint, the tinc- 
ture of iodine, or moderately stimulating embrocations, applied to the 
joints, involve no danger and are useful. 



CHAPTER VL 

ERYSIPELAS. 

The term erysipelas is applied to a constitutional or blood disease, 
which is characterized by inflammation of the skin and subcutaneous 
connective tissue, and by a tendency to spread. It is accompanied by a 
burning and pricking sensation, swelling, and subcutaneous infiltration. 

In rare instances, in young infants, an inflammation which has been 
designated erysipelas occurs in and around the umbilicus. It commences 
about the time of the detachment of the umbilical cord, and is accom- 
panied by redness of the skin, tumefaction, and hardness of the connective 
tissue surrounding the umbilicus. It usually causes ulceration of the um- 
bilical fossa, and, in fatal cases, pus is sometimes found in the umbilical 
vessels. This disease does not show any tendency to spread ; the diameter 
of the inflamed surface is not more than three or four inches, with the 
umbilicus at the centre. It is generally fatal ; but two favorable cases 
have been reported to me, in one of which there was considerable ulcera- 
tion, and after recovery a firm cicatrix occupied the site of the umbilicus. 
The most reasonable view is that this disease is primarily an inflammation 
of the umbilical fossa and vessels, induced by uncleanliness, cachexia, or 
other cause. It lacks the distinguishing feature of erysipelatous inflam- 
mations, namely, the tendency to spread, and I shall therefore take no 
further notice of it in this connection. (See Diseases of the Umbilicus.) 

Erysipelas seldom occurs in childhood ; the few cases which are met in 
this period present nearly the same features, and pursue nearly the same 
course, as in the adult. In infancy, on the other hand, erysipelas is a 
common disease. Every practitioner is called to cases, from time to time. 
The following remarks relate to erysipelas occurring in this period of life. 
They are based on data derived mainly from the records of cases which oc- 
curred in this city, some in my own practice, and others in the practice of 



ERYSIPELAS. 



313 



physicians known to be good observers. The points of chief interest in 
forty-one cases are embraced in the following table : 

Cases of Infantile Erysipelas. 



6 
'A 


i 


■ 


M. 


2 


M. 
M. 
F. 


I 


F. 
M. 


7 
8 


F. 
F. 


9 




10 


F. 


11 
12 


F. 
F. 


13 


F. 


14 


F. 


15 
16 


F. 

M. 


17 
18 


F. 
F. 


19 
20 
21 


F. 
M. 
M. 


22 


M. 


23 


F. 


24 
25 


F. 
F. 


26 




27 


F. 


28 


M. 


29 


M. 


30 


F. 


31 




32 


F. 


33 


M. 


34 


M. 


35 


M. 


36 


M. 


37 




38 
39 
40 


::: 


41 


M. 



Age. 



2 years. 
10 months. 
20 months 

9 months 
9 days. 



4 weeks. 
3 months 



4 to 5 mos, 
5 months, 



3 months. 
8 months. 



4 months. 
7 mouths. 



7 day.=. 
14 days. 

3 months. 

28 months. 

?. or 4 days. 
33^ mos. 

7 months. 
6 months. 

19 months. 

4 months. 
2 months. 

3 to 4 mos. 

4 months. 
2 months. 
5^^ mos. 
^Yn mos. 

8 months. 

5 months. 



5 weeks. 
2 mouths. 
4 months 



Point of 
commencement 



Eight knee. 

Left knee. 
Elbow. 
Below right 

knee. 
Vulva. 
Genitals. 

Vulva. 

At or near the 
ear. 

Epigastric re- 



At angle of 

mouth. 
Vulva. 
Vulva. 

Vulva. 

From syphilitic 
sores around 
anus. 

Vulva. 

Face near nos- 
trils. 

Vulva. 

Knee. 

Near the ear. 
Left eyelid. 
Genitals. 



Eight shoulder 

Vulva. 
Under left ear. 

Bi'low right 

knee. 
Vulva. 

Near point of 

vaccination. 
Near point of 

vaccination. 
Near vaccine 

vesicle. 
Near vaccine 

vesicle. 
Near vaccine 

vesicle. 
Near vaccine 

vesicle. 
Near point of 

vaccination. 
Near point of 

vaccination. 

Near vaccine 

vesicle. 
Left foot. 



At one ear. 
Left leg. 
Near point of 
vaccination. 
Face. 



Parts affected. 



Entire surface, except face and scalp. 

From a little above the knee to the ankle. 

Whole arm and forearm. 

Entire leg, thigh, and trunk to the um- 
bilicus. 

Abdomen, chest, and all the extremities. 

Both lower extremities, abdomen to the 
umbilicus. 

Entire surface, except face. 

Forehead and side of face. 



Trunk and lower extremities. 

Entire face and scalp. 

Entire surface, except face. 

Surface of abdomen to umbilicus and 

right lower extremity. 
All the limbs and the trunk, except the 

chest. 
Trunk and both lower extremities. 

Entire trunk and both upper extremities. 
Entire trunk and both upper extremities. 

Entire trunk and all the extremities. 

A portion of trunk and both lower ex- 
tremities. 

Entire face and forehead. 

Left side of face. 

Extended to knees, over abdomen to the 
chest. 

Chin, left cheek, neck, left side of trunk, 
left tliigh, and leg. 

Arm and forearm. 

Body and all the limbs. 
Neck, chest, and arms. 

Trunk, neck, and head, and all the limbs. 

Both thighs, and nearly entire trunk. 

Shoulder, arm, and forearm. 

Chest, and both upper limbs. 

Trunk and all the mbs. 

Arm, forearm, and shoulder on one side. 

Arm, forearm, and trunk. 

Nearly entire surface. 

Arm and forearm. 

Arm. 

Arm and forearm. 

Leg, thigh, and lower part of trunk. 



Entire surface. 

Trunk, and all the limbs. 

Trunk, and all the limbs. 

Trunk, and all the limbs. 



7 days. 

17 days. 
2 weeks. 



2 weeks. 
2 weeks. 
2 weeks. 



Sweeksand 


Recovered. 


3 days. 




7 days. 


Recovered. 




Recovered. 


7 days. 


Recovered. 


18 days. 


Eecovered. 


6 days. 


Died. 


6 weeks. 


Eecovered. 


1 week. 


Died in 




tetanic 




spasms. 


2 weeks. 


Died in 




tetanic 




spasms. 


10 days. 


Eecovered. 


3 weeks. 


Died. 


2 weeks. 


Eecovered. 


3 to 4 weeks. 


Died. ■ 


3 weeks. 


Recovered. 


About 2 


Recovered. 


weeks. 




1 week. 


Died. 


3 weeks. 


Eecovered. 


10 days. 


Recovered. 


3 days. 


Died. 


4 days. 


Died. 


Iday. 


Died in con- 






12 days. 


Died. 


About 2 


Died. 


weeks. 




2 weeks. 


Died coma- 




tose. 


3 days. 


Died coma- 




tose. 


21 days. 


Recovered. 


2 weeks. 


Recovered. 


10 days. 


Died. 


2 to 3 weeks. 


Died. 


2 months. 


Died. 


1 week. 


Died with 




peritonitis. 





Recovered. 



Died prob- 
ably of 
peritonitis. 
Died. 

Died with 
pneumo- 
nitis. 

Recovered. 

Recovered. 

Died. 

Recovered. 



314 ERYSIPELAS. 

Age. — Of the above eases, 27 were under the age of six months; 9 from 
six mouths to twelve, and only 5 above the latter age. A large majority, 
therefore, of cases of infantile erysipelas occur in the first year of life. 

Point of Commexcement. — In 58 cases in which I have ascertained 
the point of commencement, it was in 13 cases the vulva, 17 the arm after 
vaccination, 7 the leg, 6 the face, 3 the male genital organs, 3 at or near 
the ear, 1 the elbow, 1 the shoulder, 1 the nates, 1 the foot. In the adult, 
idiopathic erysipelas commonly commences upon the face, and affects only 
the face, ears, forehead, and scalp. On the other hand, in infantile ery- 
sipelas, statistics show that the rash commences upon the face only in a 
small proportion of cases, one in nine, and that it rarely extends to the 
face when it commences in other parts. 

Causes. — In erysipelas the first departure from the healthy state occurs 
in the blood, or the system generally. This undergoes certain changes 
which predispose to erysipelas, or are sufficient in themselves to give rise 
to it. Among the causes which produce this state of system, uncleanli- 
ness, residence in damp, dark, and crowded apartments, and defective 
alimentation, hold a principal place. Hence this di-sease is more common 
in the poor quarters of the city than in the country, and in dispensary and 
hospital than in civil practice. 

In a large proportion of cases there is a local exciting cause of the ery- 
sipelatous eruption, namely, an irritation or inflammation at some point, 
generally trivial, but which is sufficient to develop the disease in the sys- 
tem already prepared for it. It is very apt to commence at or near a 
simple ecthymatous or impetiginous eruption, around burns or suppurating 
sores or syphilitic eruptions ; it frequently commences, as is seen by the 
above table, near the point of vaccination immediately after vaccination, 
or when the pock is developed, or again when it has run its course and 
been detached. In a considerable proportion of cases it commences at a 
point where the skin is thin and delicate, or where it unites wnth a mucous 
surface, probably from some uucleanliness or irritation of those parts. 
Thus, I have records of cases in which it commenced at the external ear, 
commissure of the mouth, and at the vulva. Indeed, the frequency with 
which it commences at the vulva renders female infants more liable to it 
than males. In some instances erysipelas begins without any local ex- 
citing causes, upon smooth and sound skin, even when there are sores upon 
various parts of the surface. 

Vaccination, as an exciting cause of erysipelas, demands particular no- 
tice. Often, doubtless, it is the inflammation which necessarily arises from 
the cut or the vesicle, which operates as an exciting cause of the erysipela- 
tous affection, and not any deleterious property contained in the virus 
which is employed, so that an equal degree of inflammation occurring in 
any other way, as from a burn, Avould be attended by a like result. But 
facts show that the virus itself occasionally contains a latent noxious prin- 



CAUSES. 315 

ciple, which, introduced into the system, operates as a cause of erysipelas. 
Thus, a little girl was vaccinated by me in ISTovember, 1860, and about 
the time when the vesicle began to fill she was seized with severe inflam- 
mation of the fauces, attended by tumefaction and infiltration of the sub- 
mucous connective tissue. The inflammation rapidly subsided, and within 
a week from its commencement the throat affection had nearly or quite 
disappeared. I now believe that the disease of the fauces was erysipelatous, 
although it was not suspected at the time to have this character. 

As the girl was otherwise healthy, and the vaccine vesicle passed through 
its usual stages, and presented the usual appearance, the scab was employed 
six weeks afterwards to vaccinate two infants. Within twenty-four hours 
after vaccination both these infants were seized with high fever, ushering 
in severe erysipelas, commencing in one around the point of vaccination, 
and in the other around syphilitic sores near the anus. In the former 
case the erysipelatous rash extended from the shoulder over the entire limb, 
and was obstinate, twice reappearing, and extending over the same surface; 
in the latter (a mulatto child) it extended over both lower extremities and 
a considerable part of the trunk, when the case passed into the hands of 
another physician, and the result is not known. The instrument with 
which the vaccinations were performed was clean. The vaccine disease 
did not appear in either of these cases. 

Again, a well-known physician of this city vaccinated three infants, one 
his own (No. 32 of the table), with part of a scab which had been pro- 
nounced good, but was taken from a child that he had not seen, and with 
whose state he was not familiar. These infants were all affected with 
erysipelas from the vaccination, his own dying. He had taken the pre- 
caution to rub the lancet on his boot before using it. Another physician 
of this city has informed me that he vaccinated two children in the same 
family with a scab, with all the precautions that he had ever used, and 
both were soon after affected with erysipelas of a severe form, extending 
from the point of vaccination ; the vaccine disease did not appear. I know 
of no case in which the vaccine lymph gave rise to erysipelas, and, prob- 
ably, it rarely or never does. In the lymph there is no admixture of 
foreign substances, whereas in the scab there is a large proportion of 
animal matter. 

There is a form of erysipelas which occurs in the infant immediately 
after birth, and which is sometimes met in private practice, but is most 
frequently observed as an epidemic in lying-in wards. It is associated 
with severe, and commonly fatal, puerperal fever (metro-peritonitis), or 
erysipelas of the mother. This form of erysipelas is fatal, almost without 
exception, and its contagiousness is generally admitted by those who have 
had an opportunity to observe cases. 

A case showing this relation of erysipelas in the newly-born infant to 
disease of the mother occurred in the practice of Dr. Learning, of this city. 



31G ERYSIPELAS. 

A woman gave birth to a healthy infant, on the 27th of July, 1860. A 
few days subsequently she was seized with a chill, followed by erysipelas, 
comnieuciug on the thighs, and terminating fatally August 17th. As no 
autopsy was allowed, the state of the internal organs w^as not ascertained. 
A few days before her death the same disease commenced on the infant. 
It extended around the neck, upon the ears, down the arms, and termi- 
nated fatally August 24th. But erysipelas in the new-born infant occur- 
ring in connection with erysipelas in the mother, is more rare than its 
occurrence with puerperal fever. The records of lying-in asylums furnish 
many examples of epidemics of puerperal fever, in which the infants of 
affected mothers perish of erysipelas. 

The late Dr. Folsom, of this city, furnished me the following sketch of 
cases which occurred in his practice and that of his partner : " About the 
year 1840, being then in practice in New Bedford, Mass., I was called to 
visit a man who complained of pain in the knee. The next morning he 
was easier, but the following evening his symptoms grew worse, and as I was 
engaged in a case of obstetrics, my partner. Dr. E. C, now dead, visited 
him. At my call, next morning, I unexpectedly found the patient dying. 
The disease was obscure, and at the autopsy next day no lesion was dis- 
covered. In making the examination, Dr. G. pricked his finger, and ex- 
periencing little inconvenience from it at first, he attended a case of con- 
finement on the following morning. A few hours subsequently he w'as 
taken sick, and I took charge of the lady, who died in three days, having 
the tumid abdomen and symptoms of childbed fever. The infant of the 
patient was seized, when two days old, with erysipelas, appearing on the 
face and in spots on the trunk and limbs, and terminating fatally in 
one day. Dr. C.'s finger becanie swollen and painful, and the lymphatics 
of the forearm and arm became inflamed, presenting red lines, and the 
axillary glands suppurated. Though feverish and much prostrated, there 
was no appearance of erysipelas in his case. In about two weeks he re- 
sumed practice, and as at that time physicians in this country were not 
fully aware of the danger of communicating puerperal fever, he attended 
two, three, or four obstetrical cases each week, until the number reached 
fifteen. All the mothers died with symptoms of metro-peritonitis, and all 
the infants had erysipelas, commencing on the face or some part of the 
body, generally on the second or third day after birth, and in all termi- 
nating fatally within a w^eek. This sad record was finally ended by the 
doctor's temporarily retiring from practice." 

Dr. Condie, in his Treatise on Diseases of Children, snjs : "Erysipelas 
of infants very commonly occurs during the prevalence of epidemic puer- 
peral fever Children of mothers who become affected with the fever are 
often born with erysipelatous inflammation ; others are attacked almost 
immediately after birth. Whether, in these cases, the disease is to be re- 
ferred to a morbid matter applied to the skin in the womb, or to the same 



SYMPTOMS. 317 

epidemic or endemic influence which gives rise to the disease of the parent, 
it is difficult to say. According to M. Trousseau, infantile erysipelas is 
principally observed when puerperal fever prevails in the w^ards of the 
lying-in hospitals at Paris." In private practice it is rare that we meet 
erysipelas of the infant associated with erysipelas or with puerperal fever 
in the mother. Some of the oldest physicians of this city, with Avhom I 
have conversed, and who are engaged in extensive general practice, state 
that they have never met a case in which there was this relation. Cases 
like those observed by Drs. Folsom and Leaming only occur when epidemic 
erysipelas or puerperal fever is prevailing. 

Premonitory Symptoms. — Infantile erysipelas in certain cases has no 
premonitory stage, or, if present, it escapes notice. In other instances 
there are well-marked precursory symptoms, as drowsiness, or restlessness, 
febrile movement, oppressed respiration, with perhaps vomiting, and start- 
ing or twitching of the limbs. In Cases 28 and 37 of the table, which 
occurred in my practice, the febrile movement, restlessness, and oppressed 
respiration were so great for three days before the appearance of the erup- 
tion, as to cause much anxiety. In the adult, pharyngitis often precedes 
the occurrence of the rash upon the skin. The same inflammation may 
be present in the premonitory period of infantile erysipelas, as well as 
during the period of erysipelatous eruption. The hurried and difficult 
respiration, which is present in the commencement of some cases, is prob- 
ably due to an erysipelatous turgescence of the bronchial mucous mem- 
brane. 

Symptoms. — The patient with this disease is usually restless, in conse- 
quence of the burning pain which accompanies the eruption. In severe 
cases there is little sleep, night or day, except from medicine. The sleep 
is short, and is often interrupted by sudden starting, or twitching of the 
limbs. Convulsions may occur, but are not common. 

Febrile movement is constant, and is proportionate to the extent and 
gravity of the erysipelas. I have notes of cases in which the pulse was 
more than 200 per minute, although other symptoms did not indicate im- 
mediate danger. The skin not afl'ected by erysipelas is dry and hot, though 
not possessing the pungent heat of the inflamed portion ; face often flushed ; 
tongue moist, and covered with a light fur; stomach usually retentive. 
The state of the bowels varies ; sometimes they are regular, sometimes 
variable, while in other cases the stools are green, and more frequent than 
natural. I have records relating to the state of the bowels in twenty cases, 
as follows : in seven, regular ; in nine, loose ; in two, constipated ; in one, 
constipated, then loose ; and in one, constipated, then regular. Diarrhoea, 
when present, is usually mild, requiring little or no treatment. The ery- 
sipelatous redness is not in all cases so pronounced as in the adult, but 
otherwise there is nothing peculiar in its appearance. In feeble infants, 
with an impoverished state of the blood, its color is pink, instead of the 



318 ERYSIPELAS. 

deep red which characterizes the inflammation in the robust. Points of 
vesication may occur where the inflammation is most severe, as in the 
adult, and subsequently the same desquamation and oedema. 

If the infant is debilitated, there is great danger of the formation of 
abscesses, around which the inflammation lingers after it has disappeared 
from every other part of the body. Sometimes also, in very young infants, 
gangrene occurs, especially of the genital organs in the male. Several of 
these cases have been related to me, all under the age of a month or six 
weeks, and all fatal. Occasionally the sloughing is so great as to denude 
the testicles. A noteworthy feature of erj^sipelas in infants is its proue- 
ness to return. When it has been progressively subsiding, and hope is 
entertained of its speedy disappeai-auce, it not infrequently is suddenly 
relighted from some unknown cause, travelling again over the same, or 
parts of the same, surface. In one case the disease, arising from vaccina- 
tion, extended three times over the arm and forearm ; and in another case, 
a second time over both legs and a considerable part of the trunk. 

The internal inflammations, which most frequently complicate erysipe- 
las, and give rise to symptoms which are superadded to those pertaining 
to the erysipelas, are pharyngitis and peritonitis ; and more rarely broncho- 
pneumonia or enteritis. In a case which I examined after death, in the 
I^ursery and Child's Hospital, and in which the erysipelatous inflamma- 
tion having extended over the abdomen, the lesions of peritonitis were pres- 
ent, it seemed probable, from the thinness of the abdominal walls, that the 
inflammation had extended through the parietes from the external to the 
internal surface. 

Prognosis. — Erysipelas is much more fatal in infancy than in adult life. 
In the death statistics of this city for three years, I find eighty deaths from 
erysipelas of infants under the age of one year, to eighty -three deaths from 
this disease above that age. Age greatly influences the prognosis. Infants 
under the age of three weeks usually die ; from the age of three weeks to 
six months the result is doubtful ; while above the age of six months a 
majority recover with correct treatment. It will be seen by the foregoing 
table that seven infants under the age of six weeks had erysipelas, and six 
died ; from the age of six weeks to six mouths, six recovered and nine died ; 
and above the age of six months, nine recovered and four died. 

With the exception of a case of the so-called umbilical erysipelas, the 
youngest child who recovered, of whom I have obtained information, was 
three weeks old. In this case the rash extended nearly over the entire sur- 
face, beginning with the face. Case 38 of the table, treated by myself, was 
very similar as regards the extent of the erysipelatous eruption and the 
result. This infant was five weeks old. 

It is scarcely necessary to state that erysipelas is more favorable when it 
aflTects the limbs than when it invades the head, neck, or body; when it 
spreads slowly than rapidly ; when it is superficial than when phlegmonous. 



PATHOLOGICAL ANATOMY. 319 

In those cases in which the connective tissue is much involved, the infant 
is not always safe after the disease has run its course ; he sometimes dies 
exhausted from the discharge of abscesses : I have records of two such 



Duration. — In sixteen cases that recovered, the disease terminated 
within the first week in two, the second week in six, the third week in five, 
fourth week in one, and in two cases it lasted five and six weeks. The 
average duration was fifteen days. In nineteen fatal cases, ten died within 
the first week, five the second week, three the third week, and one in the 
fourth week. The average duration of fatal cases was about ten days. 

Modes of Death. — Death occurs in different ways ; in clonic or tonic 
convulsions followed by coma, from exhaustion, and from internal inflam- 
mation, that from exhaustion being probably the most common. 

Pathological Anatomy. — The blood doubtless in this disease under- 
goes certain pathological alterations previously to the occurrence of the 
eruption, but the exact changes are not known. Our knowledge of the 
morbid anatomy of erysipelas relates chiefly to the local affections, which, 
with the exception of the inflammation of the skin, are not constant, and 
may, therefore, be regarded as complications. The cutaneous inflammation 
affects all the structures of the skin, and in greater or less degree also the 
subcutaneous connective tissue. The inflammation is accompanied by more 
or less serous effusion or oedema. 

The not infrequent occurrence of peritonitis in connection with erysipelas 
has long been known. In Heberden's Epitome Morhorum Puerilium, the 
anatomical character of erysipelas is expressed in one sentence : " When 
the body has been opened after death, the intestines have been found glued 
together and covered with coagulable lymph." Since Heberden's time, 
nearly all who have written on diseases of infancy and childhood have 
mentioned peritonitis as one of the most common complications. Under- 
wood says: "Upon examining several bodies after death, the contents of 
the body have frequently been found glued together and their surface cov- 
ered with inflammatory exudation, exactly similar to that of women who 
have died of puerperal fever." Similar remarks in reference to the fre- 
quency of peritonitis in this disease are made by recent writers. 

The statistics in reference to erysipelas as well as peritonitis show that in 
infants in hospital practice, and in those affected by erysipelas during epi- 
demics of puerperal fever, peritonitis is a not infrequent complication. On 
the other hand, as we commonly meet cases of infantile erysipelas occurring 
sporadically in private practice, there is not sufficient abdominal disten- 
sion and tenderness to indicate peritonitis. In only one of the cases em- 
braced in the foregoing table was a post-mortem examination made, and 
in that there had been no peritonitis. The occurrence of pharyngitis in 
connection with erysipelas has been already alluded to. 

Enteritis has been alluded to as another complication in infants. Diar- 



320 ERYSIPELAS. 

rhoea has been stated to be a symptom in certain cases ; it has been found 
to be dependent on enteritis of a mild grade. Billard made post-mortem 
examinations of sixteen cases of infants dying of erysipelas, and " found 
in two gastro-enteritis, in ten enteritis, in three pneumonia complicated 
with enteritis and cerebral congestion, and in one pleuro-pneumonia." 

Treatment. — On this side of the Atlantic great uniformity prevails as 
regards the treatment of erysipelas. Sustaining measures are prescribed, 
and the tincture of the chloride of iron is the tonic generally preferred. 
Whatever the intensity of the febrile reaction and the stage of the disease, 
if there is no intestinal complication, ferruginous or other tonics should be 
administered. The largest doses of the tincture of the chloride of iron 
given in any of the cases in the above table were in case No. 4, namely, 
ten drops every two hours, and this patient recovered in seven days from 
a pretty severe attack. Probably, however, nothing is gained by such 
large doses, and they may irritate the intestinal surface, and increase the 
liability to enteritis, which, we have seen, complicates a certain proportion 
of cases. Two drops may be given every three hours to a child from one 
to two years of age. . Instead of the iron, or in addition to it, one of the 
preparations of cinchona may be prescribed. Beef tea, and in most cases 
wine-whey or other alcoholic stimulant, are required. 

The depressing measures recommended by certain writers cannot be too 
strongly censured. One author says : " We should endeavor from the first to 

allay the inflammation of the skin by energetic treatment Local 

abstraction of blood, by means of one or two leeches applied at the cir- 
cumference of the primary seat of the erj^sipelas, should be put in force, 
provided the power of the constitution of the children permits." Such 
treatment may explain one of this author's aphorisms, namely, the erysipe- 
las of infants is a fatal disease. 

Local treatment may be employed to arrest the extension of the inflam- 
mation, but the result in most cases is not encouraging. Solid nitrate of 
silver was employed in two cases, of which I have records, and in both the 
result was pernicious. Troublesome sores were produced, from which blood 
escaped, and in one of the cases, at least, death was attributed by the 
parents to this treatment, rather than to the disease. 

Tincture of iodine is a better remedy for arresting the extension of ery- 
sipelas. It should be applied from the margin of the inflammation, over 
the sound skin, to the distance of about two inches. It may be ineff*ectual, 
but it does not produce any unfavorable result. Soothing applications, 
like rye flour, or a lotion of sugar of lead, may be made to the inflamed 
surface, as in erysipelas of the adult. I prefer, however, for local treat- 
ment, the constant application of glycerin or glycerin and water, to which 
a few drops of carbolic acid are added. 



PART III. 



SECTION I. 

DISEASES OF THE CEREBRO-SPINAL SYSTEM. 

Diseases of the brain and spinal cord are less frequent than those of 
the respiratory and digestive systems. They are also less amenable to 
treatment, and are much more fatal. They largely increase the aggre- 
gate of deaths. They contrast with the diseases of the other systems in 
their greater relative frequency in infancy and childhood than in adult 
life. This is explained, as regards the brain, by the rapid development 
of this organ in early life, its feeble consistence, its great impressibility by 
the emotions, and the thinness of the covering which protects it from ex- 
ternal agencies. 

Some of the most interesting of the cerebro-spinal diseases which are 
to engage our attention, are peculiar to early life, as tetanus infantum. 
The diseases of this system also contrast with other local affections in their 
greater obscurity, especially in their commencement; for while maladies 
of the thorax can be readily ascertained by auscultation and percussion, 
or those of the abdomen by the nature of the evacuations or the degree of 
tenderness or distension, our means of conducting examination through 
the bony encasement of the cerebro-spinal axis are meagre and unsatisfac- 
tory. The conditio*! of the brain and spinal cord must be determined, 
chiefly, by the study of symptoms, and not by direct examination. The 
condition of the anterior fontanelle in young infants, however, enables us 
to determine the presence or absence of active congestion of the brain. 
If there is an excess of arterial blood, it is convex. Prominence of the 
fontanelle is common in inflammatory and febrile diseases, and is a sign 
of considerable diagnostic and prognostic value. 

Within a few years, the ophthalmoscope has been employed as a means 
of diagnosis in cerebral diseases, and although the employment of this in- 
strument for such purpose is but recent, enough has been elicited to prove 
its great value as an aid in determining the state of the brain. Prof. H. 
D. Noyes remarks on this subject: .... "The argument for making 
ophthalmoscopic examination in all cases of brain disease, becomes irre- 

21 



322 DISEASES OF THE CE REB RO-SPIN A L SYSTEM. 

sistible. Indeed, a momeut's reflection would lead to this conclusion with- 
out any considerations drawn from pathology. The optic nerve is only an 
outlying portion of the brain; its extremity is fully exposed to view. Sit- 
uated within about two inches of the brain, it is the only nerve in the 
body which we can inspect; it contains bloodvessels which communicate 
directly with the intracranial circulation. We thus come into relation 
with the cerebrum, by continuity of nerve-structure and also of blood- 



Structural changes in the optic nerve and retina have been discovered 
by means of the ophthalmoscope in meningitis, hydrocephalus, phlebitis 
of the sinuses, apoplexy, etc. Among the lesions which have been ob- 
served by this instrument, are hyperemia, more or less opacity and tume- 
faction of the optic nerve, engorgement of the vessels of the retina, with 
serous or sero-fibrinous exudation and ecchymotic points. In certain pro- 
tracted diseases, as chronic hydrocephalus, in which dimness or loss of 
sight occurs, the ophthalmoscope discloses a state of atrophy of the optic 
nerve. Heretofore the ophthalmoscope has been chiefly employed by ocu- 
lists, but as it comes into more general use, there can be little doubt that 
it will be recognized as an important aid in the diagnosis of obscure cere- 
bral diseases. 

Still, with all possible aids to diagnosis, the obscurity which attends the 
invasion of many of the cerebro-spinal diseases must be acknowledged. 
To the hasty and careless physician, their symptoms are often deceptive. 
Careful weighing of the phenomena, and thorough and protracted exam- 
ination, are requisite in order to insure correct diagnosis and proper treat- 
ment. Some of the cerebro-§pinal affections are, in reality, sequelae of 
other diseases, as, for example, spurious hydrocephalus ; and some are, 
strictly speaking, only symptoms, as convulsions ; but, on account of their 
importance, and because they require special treatment, it is proper to 
consider them as diseases |)er se. 

The brain presents certain peculiarities in infancy and childhood. In 
the foetus, while the other organs are well formed, #he brain, especially 
its cerebral portion, is still diffluent, and at birth it has so little consis- 
tence that it must be handled carefully to prevent laceration. This soft- 
ness is due to the large proportion of water which it contains. The follow- 
ing analyses show the composition of the brain in the three periods of life: 

Infant. Youth. Adult. 

Albumen, 7.00 10.20 9.40 

Cerebral fats, 3.45 5.30 6.10 

Phosphorus, 80 1.65 1.80 

Osmazomc, salts, 5.9G 8.59 10.19 

Water, 82.79 74.26 72.51 

At birth the brain has a nearly uniform white color. The gray sub- 
stance, in which the nervous power originates, is undeveloped. The date 



ACEPHAI.US ANENCEPHALUS. 323 

of its appearance corresponds with the first exhibition of emotion or intel- 
ligence, and the decided gray color which we observe in the brain of the 
adult does not appear until the age of full mental activity. 

In the new-born the brain is large in proportion to the rest of the body, 
and its growth during infancy and childhood is rapid. Until the fifth 
year, as appears from the observations of Dr. Peacock, its weight is about 
one-seventh or one-eighth that of the entire system, the proportions vary- 
ing somewhat in different cases. 

The brain does not attain its full size, as stated by Dr. West, at the age 
of seven years, but, according to Dr. Peacock's statistics, it continues to 
increase till the age of twenty-five or thirty, although its growth is less 
rapid after the age of seven years than previously. 

The membranous covering of the cerebro-spinal axis is scarcely less 
interesting to the pathologist than the axis itself I shall speak in the 
following pages of the arachnoid and cavity of the arachnoid, for conve- 
nience of description, although aware of the fact that some eminent 
authorities, as Virchow and Kolliker, whose opinions in reference to the 
minute anatomy of the system always command attention, if not assent, 
believe that there is no arachnoid, but what has heretofore been called by 
this name is on the one side the smooth surface of the dura mater and on 
the other of the pia mater. 

The dura mater is seldom involved in the diseases of early life, except 
as it is affected by pressure, while the pia mater and arachnoid are the 
seat and source of some of the most important diseases, as meningitis, 
meningeal apoplexy, etc. 

The more complicated and delicate the structure of an organ, the more 
liable it is to errors of nutrition and growth. There is, therefore, no organ 
which is so liable to irregular development as the brain. It may be en- 
tirely wanting ; or it may be partially developed, certain portions being 
absent ; or, lastly, its growth may be excessive, constituting a true hyper- 
trophy. 



CHAPTER I. 

ACEPHALUS— ANENCEPHALUS. 

Entire absence of the encephalon is not common, but there are many 
cases of this monstrosity on record. In extreme cases the head and part 
of the neck, as well as the brain and medulla oblongata, are absent. 
When there is great deficiency there is often a twin, the presence of which 
has interfered with the full development of the system. Sometimes the 
growth of other organs besides the brain is imperfect. 



324 ACEPHALUS ANENCEPHALUS. 

Anatomical Character. — In the ordinary form of aneucephalus the 
brain and sometimes the medulla are absent, with the absence or imper- 
fect development of their membranous and osseous covering. The vault 
of the cranium is absent. There is deficiency of the frontal, parietal, 
and occipital bones, except those portions which are near the base of the 
cranium. These portions are very thick and closely united, as if there 
were the usual amount of osseous substance, but, instead of expanding 
into the arch, it had collected iu au irregular mass at the base of the 
cranium. 

The absence of the brain and the cranial arch gives a remarkable ap- 
pearance. The eyes are prominent, the neck thick and short, while the 
P^^ body and limbs are ordinarily well de- 

veloped. The physiognomy has been 
compared to that of some of the lower 
animals. 

The base of the cranium is often oc- 
cupied by a vascular tumor, not large, 
but of different size in different cases, 
and continuous below with the spinal 
pia mater. This vascular tumor is the 
representative of the cranial pia mater, 
and its smooth surface is the analogue 
of the arachnoid. The dura mater and 
the scalp being absent, the exposed mass resembles very much in appear- 
ance, as it does iu structure, the placenta, and the sensation which it 
imparts to the finger pressed upon it is very similar. Sometimes small 
portions of cerebral matter are found among the vessels of this tumor, 
but they are so disconnected or isolated that they do not perform, in any 
way, the function of a brain. Occasionally the vascular tumor is absent, 
and the medulla or upper extremity of the spine is exposed, or it termi- 
nates in a little papilla at the back of the neck. 

Those portions of the cranial nerves which lie external to the cranium 
are well developed, although the intracranial parts may be absent. 

Symptoms. — The respiration in anencephalous monsters is irregular. 
They can be made to cry, but their cry is a sort of sob or hiccough, and, 
occasionally, they even nurse. The digestive function is well performed, 
and regular urinary and fsecal evacuations occur. There is a tendency in 
anencephalous monsters to convulsions. Blowing upon them, and pressure 
upon the projecting medulla, if this is present, frequently produce this 
effect. 

Prognosis. — Fortunately these monsters are short-lived. If the medulla 
oblongata, which is essential to the maintenance of respiration, is absent, 
extra-uterine life is impossible. Stillbirth is the result. If the medulla 
oblongata is present, although respiration and circulation are established. 




IMPERFECT BRAIN. 325 

death commonly takes place within two or three days, and almost always 
within the first week. Convulsions sooner or later occur, ending in fatal 
coma. 



CHAPTER 11. 

IMrERFECT BRAIN. 

Between the absent and complete brain there are various grades of de- 
ficiency. Parts of the brain may be perfect, while other portions are either 
absent or imperfectly formed. The deficiency is usually in the superior 
parts of the brain, especially in the hemispheres of the cerebrum, while 
the base of the organ is perfect. Both hemispheres may be absent, or one 
may be absent, while the other hemisphere is shrivelled or rudimentary. 
Occasionally the cranium preserves its normal shape and size, in conse- 
quence of an increase in the cerebro-spinal fluid proportionate to the lack of 
brain-substance. The imperfect development is not then apparent to the 
observer. The rudimentary hemispheres in these cases are spread out, 
forming the walls of a sac inclosing the liquid. The post-mortem exami- 
nation of the following case was made in the Nursery and Child's Hospital, 
of this city, in 1862. 

Case. — Female ; parentage healthy ; she was plump and well formed at 
birth, and nothing unusual was observed in her condition, as she nursed 
and throve like other children, till she reached the age when there is, 
usually, the first manifestation of intelligence. With her there was no 
evidence of an intellect, or if anj', it was very indistinct. She nursed, or 
took food when placed in her mouth, but apparently wdthout relish, as if 
instinctively. She never reached her hands towards the nurse, or towards 
playthings. So indifferent and apparently unconscious was she of objects 
around her, that it was thought for some time that she was blind. She 
never smiled, except when her hands were gently rubbed or shaken ; and 
then the smile seemed to be more a reflex movement than emotional. The 
smile was immediately succeeded by a fixed vacant look. She usually lay 
quietly, with her arms crossed ; and during the last months of her life she 
sometimes uttered a scream, like children with cerebral diseases. Her 
evacuations were regular, and she was not subject to vomiting, before she 
was attacked with the acute disease of which she died. The size of her 
head was rather less than usual at her age, but not less than is often seen 
in well-formed children. The forehead was small in proportion to the rest 
of the head, but the difference was not such as to attract attention. For- 
tunately, the existence of this idiot was terminated by an attack of entero- 
colitis at the age of about ten months. 

tSeetio Cadav. — The head was measured, but the measurements were lost. 
They did not seem to differ materially from the normal standard. The 
sutures were united, and the fontanelles nearly, if not quite, closed. The 



326 IMPERFECT BRAIN. 

frontal bone lay a little lower than the plane of the parietal. The men- 
inges of the brain presented nearly their normal appearance, but were dis- 
tended with transparent serura. The quantity of fluid was estimated at 
about two-thirds of a pint, and when it was evacuated, the floor of the 
lateral ventricles was brought into view. There was almost an entire 
absence of that part of the brain which lies above the floor of the ventricles. 
On close inspection, rudimentary cerebral hemispheres w'ere found in a 
thin layer forming a part of the walls of the sac. The whole amount of 
brain-substance above the ventricle did not exceed the size of a small egg. 
The cerebellum, the base of the brain, and cranial nerves presented their 
usual appearance. The entire brain, after being a few days in diluted 
alcohol, weighed six and a quarter ounces. 

In this case, the fluid was only sufficient to compensate for the deficiency 
of the brain. In other, and probably the larger number of cases of in- 
complete brain, the cerebro-spinal fluid is not materially increased. There 
is then but slight elevation of the frontal bone, the forehead is low, or re- 
treating, or even almost absent. This is that shape of head which is uni- 
versally regarded as characteristic of idiocy. 

Symptoms. — The symptoms in cases of deficient brain relate to the mind. 
If the cerebral hemispheres are absent, there is no intelligence. The in- 
dividual, as regards mental endowments, does not rise above the instincts 
of the lower animals. If the hemispheres are partially developed, there 
is a degree of intelligence proportionate to the amount of cerebral substance 
present. If the deficiency is confined to one side, there is no apparent lack 
of intelligence or mental capacity, since, the brain being a double organ, 
one side performs the function of both. 

Prognosis. — The prognosis as regards life, in cases of imperfect brain, 
depends not so much on the amount of deficienc}' as the exact seat of ar- 
rested growth. If only the cerebrum is partially, or even entirely absent, 
the infant may live and thrive. But if those portions lying at the base of 
the brain, which control the functions of animal life, are lacking, or are 
imperfectly formed, life is very uncertain, and probably short. 

It is evident that no therapeutic treatment can remedy a congenital de- 
ficiency. The services of the physician are not required. The philan- 
thropic and patient teacher may impart a degree of intelligence to the 
idiotic, and the instruction of these unfortunates has of late years been 
very successful. 

Microcephalus— Atrophy of Brain. 

An abnormally small brain, or microcephalus, as it is termed, sometimes 
results from premature closing of the sutures and fontanelles. If ossifi- 
cation is so rapid that the cranial bones are firmly united, and are of such 
thickness as to be unyielding at the time when the growth of the brain is 
most active, the full development of this organ is necessarily prevented. 



MICROCEPHALUS — ATROPHY OF BRAIN. 327 

The brain is compressed, its convolutions flattened, and the functions of 
the organ are imperfectly performed. Death, sooner or later, is the com- 
mon result ; life ends in convulsions and coma. 

Again, the brain of the child, when undergoing development, with the 
cranial bones sufliciently yielding, may not only cease to grow, but may 
even diminish in size, in consequence of protracted and exhausting diseases. 
Diminution in the size of the brain occurs especially after fevers and diar- 
rhoeal affections of long standing and attended with much emaciation. 
The waste of the brain corresponds with the general loss of flesh. If the 
cranial sutures are not united, the occipital and sometimes the frontal 
bones are depressed, according to the diminished size of the brain, and are 
overlaid by the parietal. In foundlings of two or three months, this loss 
of brain-substance is often very striking. In infants of this class who have 
died of protracted diarrhoea, it is not unusual to observe the occipital bone 
not only depressed, but extending one, two, or even three lines underneath 
the parietal. 

If the child with shrunken brain, from protracted and exhaustive dis- 
ease, is old enough to express its thoughts, it often seems foolish, talks but 
little, and perhaps says the same thing over and over again. In one case 
in my practice, a little girl, having passed through a long course of typhus, 
persistently repeated during her convalescence, with a silly smile, the ques- 
tions addressed to her. This peculiarity continued two or three weeks, 
although her appetite was good, and her restoration to health rapid. In 
another case a little boy, during convalescence, was wont to laugh heartily 
at the appearance of the ordinary articles of furniture in the room. Both 
showed more impairment of mind during convalescence than in the midst 
of the fever. The friends of such children are in a state of great anxiety 
lest their minds are permanently enfeebled, but, as the appetite and strength 
return, the nutrition of the brain is re-established, and the mind regains 
its former vigor. In cases of wasted brain, with cranial bones united, the 
deficiency is supplied by serous effusion, which is gradually absorbed as 
the health of the patient is re-established, and the brain enlarges. This 
effusion occurs not only over the convexity of the brain, but also at its 
base, and sometimes in the ventricles. Dr. West states that in atrophy of 
the brain, from protracted disease, its texture is firmer than usual. I have 
not noticed this in inftints, but my attention has not been directed particu- 
larly to this point. It is probable that there is some change in the ana- 
tomical character of the brain, aside from mere waste. 

Partial atrophy of the brain sometimes, also, occurs from primary dis- 
ease located in this organ ; the affected portion wastes, while the rest 
retains its normal development. 



328 HYPERTROPHY OF BRAIN. 



CHAPTEE III. 

HYPERTROPHY OF BRAIN. 

In contrast with atrophy of the brain is the opposite state, or hyper- 
trophy. The size of this organ within the limits of health varies greatly 
in different individuals, but sometimes there is so great an increase in vol- 
ume as to properly constitute a disease. 

Pathological Anatomy. — The excess of growth which characterizes 
this disease has been ascertained to be confined to the white portion of the 
brain, and ordinarily to that part contained in the cerebral hemispheres. 
Hypertrophy of the brain is attended by induration, which exists in differ- 
ent degrees in different cases. It is in some so slight as to be scarcely 
appreciable; while in others it is apparent at once by pressure with the 
finger, or incision with the scalpel. Rilliet and Barthez state that the in- 
duration in some cases resembles in degree and appearance that produced 
by the action of alcohol. The white substance of the cerebrum is not 
only resisting and elastic, but its color is unusually pale; it presents even 
a brilliant or polished appearance. At the same time the gray substance 
is more or less faded, and its depth in the convolutions is less than in the 
normal state of the organ. Rokitansky says : " The cineritious matter is 
generally of a pale grayish-red coloi'. The medullary is always dazzling 
white, and remarkably pale and anaemic." An unusual case is related by 
Burnet, iu which the gray substance in the corpora striata retained its 
usual color, and was indurated like the white substance. In exceptional in- 
stances the cerebellum as well as cerebrum undergoes hypertrophy, becom- 
ing at the same time more or less indurated. In Burnet's case there was 
induration of the optic nerves. "The internal structure," he says, "of the 
optic nerves, especially in their bulbs, had the polish, homogeneous appear- 
ance, elasticity, and almost the hardness of cartilage." Rilliet and Bar- 
thez state that in two cases the spinal cord presented even more marked 
induration than the encephalon. Congestion is not a feature of hypertro- 
phy. On the other hand, there is often less vascularity of the brain and 
its membranes than in the healthy state. If the cranial bones are com- 
pletely ossified at the time when hypertrophy commences, and firmly 
united, enlargement of the brain is partially prevented. The convolu- 
tions are then thin, much flattened, the sulci more or less effaced, the 
membranes pale and dry, and the ventricles are small and nearly desti- 
tute of serum. At the autopsy of such a case, when the dura mater is in- 
cised, the expansion of the brain prevents the proper refitting of the skull- 



CAUSES. 329 

cap. Occasionally hypertrophy causes more or less absorption of the 
cranium, and perhaps the sutures already united are pressed apart. 

If hypertrophy commences in young infants with the fontanelles and 
sutures still open, they usually remain open, or are a long time in uniting. 
The interspaces continue, not only in consequence of the growth of the 
brain, which tends to separate the bones, but also in consequence of feeble 
ossification. The shape of the head arrests attention. Hypertrophy usu- 
ally produces most enlargement between and above the ears, while the 
frontal portion of the head, though somewhat enlarged, is less developed. 

The direction of the eyes is not changed, as is common in congenital 
hydrocephalus. 

Rokitansky says (vol. iii, page 285) : "With regard to the question to 
be decided by the theory and microscopic examination, as to the nature of 
the added material upon which the increase of volume depends, I have 
formed the following opinion from repeated investigations : 

" 1. The disease is genuine hypertrophy. 

" 2. It consists, as such, not in an increase in the number of nerve-tubes 
in the brain, from new ones being formed, nor in an increase in the dimen- 
sions of those which already exist, either as thickening of their sheaths, or 
as augmentation of their contents, by either of which the nerve-tubes 
would become more bulky; but, 

" 3. It is an excessive accumulation of the intervening and connecting 
nucleated substance." 

It is now generally admitted that the views of Rokitansky are correct ; 
that hypertrophy of the brain is due to an augmentation in the amount of 
connective tissue, which lies between and unites the tubules. 

Causes. — Hypertrophy of the brain is commonly associated with rachitis 
or scrofula, or some error in the nutritive process, which shows itself in 
other parts of the system as well as the brain. Rilliet and Barthez con- 
sider frequent congestion of the brain as a common cause of hypertrophy. 
This disease is not common in this country. It is most frequently met in 
hospitals for children, and among the poor of the cities, whose systems are 
rendered cachectic by residence in damp and dark localities, and by un- 
wholesome diet. In the deep valleys of Switzerland, and in parts of South 
America and Asia, hypertrophy of the brain is common, under the name 
cretinism. It is associated with rachitis and stunted growth. The ab- 
normal development which occux's in cretinism begins in infancy or early 
childhood, and the unfortunate subjects of it are short-lived. Cretinism 
has been attributed to a residence in localities wet and deprived in great 
measure of solar light, and to general disregard of the laws of health on 
the part of those affected as well as their parents. A recent thorough ex- 
amination of the subject lends support to the view that it is caused by the 
use of water containing one of the combinations of sulphur and iron. 

The observations of different physicians also establish a connection be- 



330 hypertrophV of brain. 

tweeu some cases of hypertrophy and the saturation of the system by lead. 
In what way lead-poisoning leads to hypertrophy is obscure, but the con- 
current testimony of different observers is so strong, that Ave cannot doubt 
that it does sometimes have that effect. 

, Symptoms. — The symptoms, as is the case with most organic diseases of 
the brain, vary considerably in different cases. Sometimes there is, at first, 
more or less depression or languor. If the child is old enough to speak, he 
may complain of pain in the abdomen or limbs, evidently neuralgic, or of 
headache. After a variable time vomiting succeeds, and finally convul- 
sions, affecting the muscles of the face, as well as extremities ; the convul- 
sions are usually clonic, but sometimes, as regards at least the extremities, 
of a tonic character. The pupils may be contracted or dilated ; there is 
restlessness alternating with drowsiness, and finally coma succeeds. 

Hypertrophy may continue a considerable time before serious symptoms 
arise ; but when once developed, these symptoms ordinarily continue with 
more or less severity till death. Death commonly results within a week 
after their commencement, but sometimes not till several weeks have 
elapsed. When death occurs at an early period in the disease, there is 
usually firm ossification and union of the cranial bones, and, therefore, but 
moderate enlargement of the cranium. 

If hypertrophy commences at a period not far removed from birth, the 
bones, of course, yield more readily to the pressure, and acute symptoms 
do not occur so soon. After a time, however, in all or nearly all cases, 
convulsions supervene. These indicate the gi-avity of the disease, and are 
prognostic of its fatal termination. 

In a patient observed by Burnet, violent convulsions, followed by loss 
of consciousness, marked the commencement of acute symptoms. Five 
days subsequently, the following symptoms were recorded : mobility of the 
eyes, without expression ; pupils contracted, and directed upwards ; di- 
vergent strabismus of the left eye ; the senses in their normal state, with 
the exception of sight ; the limbs move by volition. For a month there 
was little change. Then occurred drowsiness, and increased prostration, 
and five weeks later the child succumbed with the symptoms of double 
pneumonia. 

Such is the clinical history of hypertrophy. In cases of firm ossification 
of the cranial bones, and, therefore, no marked enlargement of the skull, 
the symptoms are similar to those which occur if the dimensions of the head 
are increased, only compression and death result sooner. 

The following case, in which the sutures were firmly united, I attended 
in 1864. The head was large, but not so large as to attract attention from 
its disproportion : 

Case. — A boy, aged two years and two months, had, when about one 
year old, fever and ague, and since then his countenance was uniformly 
pallid, and his flesh soft. Weaned at the usual time, he remained well till 



DIAGNOSIS. 331 

the 1st of January, 1864. In the beginning of this mouth he was ob- 
served to be feverish for some days, and his appetite poor. His health 
then gradually improved, and he was thought to be entirely well. 

On the 26th of February he was suddenly seized with convulsions, gen- 
eral at first, but most severe and continuing longest on the left side. The 
convulsions lasted a little more than three hours. He recovered fully his 
consciousness by the following day, but his appetite remained poor ; he 
was no longer amused by his playthings, and was very fretful. The sur- 
face w'as pallid ; bowels constipated ; pulse but little, perhaps not at all, 
accelerated. He continued in this state till the 6th of March, when he had 
another slight convulsive attack, and from this time he never fully recov- 
ered his consciousness. He was fretful if disturbed, his face generally 
pallid, while the pulse and respiration were not perceptibly altered. 

On the following day, the 7th, the left pupil was somewhat larger than 
the right, but both were sensitive to light. The difference in size continued 
till near the close of life. Although vision was imperfect, if not altogether 
lost, the sense of hearing was not impaired. 

VVhen questioned, he uniformly answered " No," with a drawling voice, 
evidently not understanding what he said. 

As the disease advanced, the respiration became at times sighing ; but 
the rhythm of the pulse was not materially altered. The temperature of 
the surface was changeable, sometimes cool, sometimes warm, and the con- 
gested spots or patches, so common in cerebral affections, were also ob- 
served at times on the face, ears, or forehead. Through most of his sick- 
ness, he took drinks readily, and the urine was freely discharged, probably 
from the iodide of potassium, which he took in one and a half grain doses 
every two hours. 

He became more and more drowsj'', again had slight convulsive move- 
ments, and finally died, with much apparent suffering, on the 14th of March. 
The pulse became more accelerated during the last two or three days. On 
the day preceding his death, the pupils were contracted, and not affected 
by the light. 

Sectlo Cadav. — Body somewhat emaciated, and eyes sunken ; occipito- 
frontal circumference of head nineteen and a half inches; distance from 
one auditory meatus to the other over the vertex, thirteen and a half 
inches ; convolutions over the surface of the brain much flattened and 
compressed ; brain generally deficient in blood ; medullary substance firm, 
and of a pure white color, meninges healthy; no other abnormal appear- 
ances were observed ; weight of brain forty-two ounces. 

Diagnosis. — The diagnosis of hypertrophy is not always easy. The 
symptoms are, in the main, such as occur in other pathological states, 
especially congenital hydrocephalus. There is most danger of mistaking 
the overgrowth for this disease. Hypertrophy has, indeed, often been 
treated for hydrocephalus. There are, however, certain signs by which 
we may distinguish one from the other. In the ordinary form of con- 
genital hydrocephalus, even when the amount of liquid is small, the orbital 
plates of the frontal bones are pressed in such a way that the axis of the 
eyes is changed so as to have a downward direction. The white of the 
eye can be seen between the iris and the upper eyelid. This gives a char- 
acteristic and striking expression to the face. The exception to this is in 



332 HYPERTROPHY OF BRAIN. 

those rare cases in which the liquid is external to the brain. In hyper- 
trophy this peculiar change in the axis of the eyes does not occur. More- 
over, in hypertrophy there is not that uniform expansion of the head which 
is observed in hydrocephalus, as has been stated above. There are, com- 
monly, greater enlargement, more prominence of the anterior fontanelle, 
and wider separation of the cranial bones, in hydrocephalus than in 
hypertrophy. 

Hypertrophy with consolidation of the cranial bones, and, therefore, 
little enlargement of the head, may be mistaken for meningitis. The his- 
tory of the case, and the means by which we diagnosticate the latter affec- 
tion, which will be described in their proper place, will usually enable the 
physician to make a correct diagnosis. 

Prognosis. — In forming an opinion as to the probable termination of 
the disease, we must have regard to the age and general condition of the 
child, as well as to the degree of hypertrophy. If the disease commences 
at an early age, w^hen the cranial bones are not firmly united, it is probable 
that there will be no compression of the brain, so as to endanger life, for 
a considerable period. We may then hope by proper measures to remove 
the constitutional state which gives rise to the hypertrophy, before the 
enlargement is such as to cause cerebral symptoms. If the bones have 
already united when the disease commences, even slight hypertrophy will 
produce symptoms, and a speedily fatal result is inevitable. Evidently, 
also, a child in a marked degree rachitic or scrofulous, is much less likely 
to recover than one whose general health and constitution are less impaired. 

Treatment. — The treatment in hypertrophy should be directed mainly 
to the constitution. Measures calculated to improve the nutritive process 
are those most likely to check the abnormal growth of the brain. As the 
disease is one of perverted nutrition, and usually coexists with a vitiated 
or impoverished state of the blood, tonic and alterative remedies are re- 
quired. The syrupi ferri iodidi is, therefore, useful, as it is both tonic and 
alterative. This may be given in doses of three or four drops to a child 
one year old, three times daily. Cod-liver oil, with or without the iron, 
is beneficial in some cases. Another remedy is iodide of potassium in 
combination with a tonic, as the compound tincture of bark. 

R. Potas. iodic! , ^j. 

Tinct. cinchon. comp., 
Syr. limonum, fia ^ij. Misce. 
One tcaspoonful, three times daily, tu a eliild of three years. 

The hygienic treatment is not less important than the medicinal. There 
is little hope of a favorable issue in any case, unless the regimen is such 
as will conduce to a more robust and healthy state of system. The diet 
should be plain and nutritious, the apartments clean and airy, and all 
undue excitement should be avoided. 



THROMBOSIS IN THE CRANIAL SINUSES. 333 



CHAPTER IV. 

THKOMBOSIS IN THE CEANIAL SINUSES (PHLEBITIS). 

The formation of fibrinous coagula within a vein or sinus is designated 
thrombosis {thrombus, clot). Coagulation of fibrin in the cranial sinuses 
occasionally occurs, constituting a very serious pathological state. This 
may result from local disease in the sinuses or in their vicinity, or from 
disease external to the cranium. The immediate cause of thrombosis, 
whatever its location, is sufiicient arrest of the circulation to allow the 
fibrin to coagulate. 

Tubercular and enlarged bronchial glands, compressing more or less the 
vense innomiuatse, or the descending vena cava, sometimes give rise to 
thrombosis in the cranial sinuses, the fibrin coagulating in consequence of 
retardation in the current of blood. I have koown thrombosis, in the 
same situation, also to result from clonic convulsions, occurring in connec- 
tion with severe spasmodic cough in pertussis, since both the cough and 
convulsions retard the flow of blood in the veins and sinuses within the 
cranium. At the post-mortem examination of three such cases I found 
whitish clots in the lateral sinuses. 

Thrombosis, in the cranial sinuses, may also occur from inflammation, 
either in the walls of the sinuses or immediately exterior to them. This 
is the disease which writers have designated phlebitis of the cranial 
sinuses, and for a correct understanding of the morbid anatomy of which 
the profession are indebted to Virchow. 

Anatomical Characters. — If a child die with the cranial sinuses 
and the veins of the brain and of the meninges in their normal state, the 
blood in these vessels is found at the autopsy dark but liquid, or there are 
small, dark, and soft clots in the larger sinuses. If there was congestion, 
but no coagulation, in these vessels in the last hours of life, the clots are 
more numerous, larger, and longer, sometimes extending from the sinuses 
into the larger veins which empty into them, but they are still dark and 
soft, readily falling to pieces when handled. If, again, there has been 
that degree of congestion and stasis which has resulted in ante-mortem 
coagulation, or in thrombosis, the clots are, in part at least, whitish, and 
of a fibrinous or gelatinous appearance ; they were formed while the red 
corpuscles were still carried along in the circulation. 

Most of the clots in thrombosis are free, w^hile others are attached 
lightly to the internal surface of the sinus; occasionally they are so large 



334 THROMBOSIS IN THE CRANIAL SINUSES. 

as to distend the vessel. They extend also in many cases into the cerebral 
veins which connect with the sinnses, producing prominence and firmness, 
so as to resemble (Rilliet and Barthez) an artificial injection. The clots 
do not present a uniform character. In parts of a sinus they consist of 
almost pure fibrin, of a yellowish-white color, while in other portions they 
present a gelatinous appearance from the large number of white corpus- 
cles, while other portions are more or less tinged from the presence of red 
corpuscles. The central part of the clot, after a time, if the case is suf- 
ficiently protracted, softens, and presents a puriform appearance. This 
substance, which is only disintegrated fibrin, was supposed to be pus, till 
the microscope revealed its true character. It is obvious that small clots 
forming within a sinus, and having no attachment to its walls, are liable 
to be carried by the current of blood into the general circulation, unless 
there is complete obstruction. Virchow has also shown how a thrombus 
may extend, by gradual prolongation, nearer and nearer the heart, so that 
one commencing in a sinus may, after a time, reach into the jugular vein. 
Different observers, as M. Tonnele, and also Rilliet and Barthez, have 
traced the fibrinous masses as far as the cava. The latter writers relate 
the case of a girl, four and a half years old, in whom the sinuses on the 
left side, especially those nearest the petrous portion of the temporal bone, 
Avere completely filled with clots of a yellowish-white color, intermixed 
with central dark spots. Similar coagula were also found in the left 
jugular vein as far as the brachio-cephalic trunk. Whether the walls of 
the sinus undergo any change depends on the nature of the disease Avhich 
causes the thrombosis. If it be phlebitis, the coats are thickened from 
infiltration and injected, and the internal coat has lost its polish. If it 
be some obstructive disease in the course of the circulation, or a general 
cause, the coats of the vessel are unaltered, except that they may be 
stained by imbibition of the coloring matter of the blood. In an infant 
who died of this disease in the practice of Dr. West, " the sinuses on the 
left side were healthy, but the blood was almost entirely coagulated. The 
posterior half of the longitudinal sinus, the torcular, the left lateral, and 
the left occipital sinuses, were blocked up with fibrinous coagulum, pre- 
cisely such as one sees in inflamed veins, and the clot extended into the 
internal jugular vein. The coats of the longitudinal, and of the inner 
half of the lateral sinus, were much thickened, and their lining membrane 
had lost its polish, was uneven, and presented a dirty appearance." 

The mode in which congestion and coagulation occur within a sinus, in 
consequence of the pressure of a tumor upon this vessel, or upon a vein 
into which the blood from this sinus flows, is sufficiently obvious. The 
mode of the production of thrombosis, as a result of clonic convulsions, or 
of the spasmodic cough of pertussis, is also apparent. How it results 
from inflammation of the walls of a sinus, that is, from phlebitis, was not 
understood till explained by Virchow. 



CAUSES. 335 

The fibrinous coagula which fill the sinus are not an exudative product, 
as was formerly supposed. Inflammation (in most cases otitis, with caries 
of the petrous portion of the temporal bone) approaches a sinus. The 
inflammatory products pressing against the walls of the sinus diminish 
its calibre at that point, and hence the retardation of the current of blood 
and the coagulation. Or the walls of the sinus may be thickened by in- 
flammatory infiltration, or even by the formation of little abscesses within 
the coats in consequence of the inflammation, so as to produce bulging 
inwards, and the result, as regards the circulation, is the same. Whether, 
therefore, the inflammation occur without a sinus, or within its walls, 
thrombosis equally results, provided that the diameter of the vessel is 
sufficiently narrowed by the presence and pressure of inflammatory prod- 
ucts. 

There is no exudation on the internal surface of a sinus or vein when in- 
flamed, as there is upon serous surfaces. " On the contrary " ( Cellular Path- 
ology, translation, p. 236), " when the wall is inflamed, the exuded matter 
(exsudatmasse) passes into the wall, which becomes thicker, cloudy, and sub- 
sequently begins to suppurate. Nay, even abscesses may form which cause 
the wall to bulge on both sides like a variolous pustule, without any coagula- 
tion of the blood ensuing in the cavity of the vessel. At other times, 
certainly, phlebitis, properly so called (and in like manner arteritis and 
endocarditis), is the cause of thrombosis, in consequence of the formation 
of inequalities, elevations, depressions, and even ulcerations upon the inner 
wall which favor the production of the thrombus. Still, whenever phlebitis, 
in the usual sense of the word, takes place, the alteration in the coat of the 
vessel is almost always a secondary one, and, indeed, occurs at a compara- 
tively late period." 

This view of the pathology of thrombosis comports with fjicts observed 
at autopsies, and which cannot be explained according to the old theory 
of phlebitis, namely, smoothness of the internal surface of the sinus; 
natural color of this sinus, or simple staining from blood ; the non-attach- 
ment or slight attachment of the coagula, etc. 

Causes. — Some of these have been already stated at the commencement 
of this article. It is evident from what has been said that this disease may 
be produced by any cause which obstructs the return circulation from the 
head. I have already alluded to tumors which press upon the sinus, or 
on the vein below the sinus, as a cause. Among the causes may be men- 
tioned also abdominal tumors, narrowing of the chest from rachitis, or 
caries of the vertebrae, and, finally, compression of the jugular vein by a 
retropharyngeal abscess. 

Sufficient allusion has already been made to inflammation of the internal 
ear as a not infrequent cause. Thrombosis is, indeed, the most dangerous 
result of chronic otitis. Another cause is a reduced or cachectic state of 
system, apart from any local obstructive disease. It is a noteworthy fact 



336 THROMBOSIS IN THE CRANIAL SINUSES. 

that a large proportion of those affected with thrombosis, even when it is 
immediately due to obstructive disease, are cachectic. The explanation of 
this fact is not difficult. In reduced states of the system the action of the 
heart is feeble, and passive congestion of the vessels within the cranium is 
apt to occur. Passive congestion of the veins and sinuses in protracted 
diarrhoeal maladies, which is described in our remarks upon another dis- 
ease, is an example in point. In this state of feeble circulation very slight 
obstructive disease may be sufficient to cause thrombosis. 

Symptoms. — The symptoms of this disease are often obscure. All of 
them may and do occur in other maladies of the encephalon. In cases re- 
lated by M. Tonnele, cei-ebral symptoms were well marked, such as faint- 
ness, dilation of the pupils, strabismus, grinding the teeth, convulsive move- 
ments. There may be an almost total absence of such symptoms as would 
direct attention to the state of the head. This is due to the sudden occur- 
rence of death in such cases after the clots have formed. If the clots are 
large, death soon results in consequence of congestion of the brain and men- 
inges, which is proportionate to the amount of obstruction. Extravasations 
of blood and transudation of serum not infrequently accompany the con- 
gestion and hasten the result. 

Dr. West relates the case of a girl who had a mild attack of scarlet fever 
at the age of eight months, and did not fully recover her health. She con- 
tinued restless and feverish, and had two violent convulsions two Aveeks 
after the scarlatina. In the following months she had anasarca, and when 
she was nearly a year old another attack of convulsions occurred. Fluctua- 
tion was now observed in the abdomen, and in a few days a sero-purulent 
fluid began to escape from the umbilicus. When this discharge had con- 
tinued eleven days, symptoms of a liquid in the right pleural cavity were 
suddenly developed. She grew weak and emaciated, and finally was seized 
with extreme faintness, with which she died in forty-eight hours, at the age 
of thirteen and a half months. 

At the post-mortem examination a large amount of pus was found in the 
abdominal and right pleural cavities. On the right side of the cranium, 
the sinuses were filled with coagula, and their coats seemed healthy. The 
left lateral and occipital sinuses, the torcular and part of the longitudinal 
sinus, also contained coagula, which extended into the jugular vein. The 
walls of the longitudinal sinus and the internal part of the lateral sinus 
were thickened, and their inner surface had lost its polish and was uneven. 
There was congestion of the brain, with points of extravasated blood. If, 
as is probable, the convulsions were due to some other cause, the only 
symptom which was clearly referable to the thrombosis was the sudden 
faintness. In the three cases of thrombosis occurring in pertussis, already 
alluded to, and in which I was enabled to ascertain by post-mortem ex- 
amination the presence and extent of the clots, the symptoms, which 
were apparently due to the thrombosis, were those of cerebral congestion. 



CONGESTION OF BRAIN. 337 

Among these symptoms, stupor, and finally coma, were prominent. The 
convulsions which occurred in both cases were apparently a cause, and not 
result, of the thrombosis. 

Diagnosis. — It is evident, from what has been said, that thrombosis of 
the cranial sinuses can rarely be diagnosticated with certainty. The pre- 
existence of otitis will sometimes lead us to suspect its presence, especially 
if the otitis has been accompanied by deepseated pains. Symptoms of 
cerebral congestion, serous effusion, or apoplexy, occurring in connection 
with otitis, protracted convulsions, or glandular or other tumors situated 
so as to compress the vessels which return blood from the brain, indicate 
thrombosis. 

Prognosis. — The prognosis, in any case, is obviously unfavorable. The 
cause is, ordinarily, permanent, or not readily removed, so that the clots 
gradually increase. If the cause is local obstructive disease, death is almost 
certain, since, in nearly every instance, the obstruction is of such a nature 
that it cannot be removed by medical or surgical treatment. It is possible 
that recovery may take place if the clots are few and small, and the cause 
of the thrombosis is mainly feebleness of circulation in consequence of a 
state of debility. We know that clots may liquefy, and their elements re- 
enter the circulation ; but such a result of thrombosis in a cranial sinus, if 
it ever occurs, is rare. The thrombus, by its presence, serves as a point of 
attachment around which more fibrin coagulates, so that the obstruction 
gradually increases till death occurs. 

Treatment. — Thrombosis should be treated by cool applications to the 
head, in order to diminish the congestion, by stimulants and sustaining 
measures in case the systolic movement of the heart is feeble. Tonics, vege- 
table or ferruginous, are indicated if there is a cachectic state. 



CHAPTER V. 

CONGESTION" OF BRAIN. 

Congestion of the brain is not peculiar to infancy and childhood, but 
is much more common in these periods of life than subsequently. This is 
due, in a great measure, to the fact that in the young the circulation is 
more readily disturbed by moral as well as physical causes than in the 
adult. 

Congestion of the brain is occasionally primary ; more frequently it oc- 
curs as a concomitant or sequel of some other affection. Diseases, whether 
constitutional or local, which in the adult have no appreciable effect on 

22 



338 CONGESTION OF BRAIN. 

the vascularity of the brain, often cause in the child a decided increase of 
blood in this organ. 

Causes. — Cerebral congestion is of two kinds, active and passive. The 
former results from a cause which directly affects the brain, and increases 
the flow of blood towards it, or from a cause operating primarily on the 
heart, and increasing the frequency and force of its systolic movement ; 
the latter is due to some obstruction in the course of the circulation, or to 
a feeble propelling power on the part of the heart. 

Among the causes which most frequently produce active congestion of 
the brain in the child, may be mentioned blows or falls on the head, ex- 
cessive fatigue or excitement, heat, perhaps sometimes dentition, and also 
various inflammatory and febrile affections, especially in their first stages. 

Cerebral symptoms occurring in the course of an essential fever are no 
doubt often due, in a great measure, to the irritating effect on the brain of 
the specific principle, whatever it may be, circulating in the blood. Oc- 
curring in inflammatory diseases which are located elsewhere than within 
the cranium, they are often attributed to functional disturbance of the 
brain. The brain, it is said, sympathizes with the affected part through 
the system of nerves which unite them. But observations show that symp- 
toms referable to the brain, arising in the commencement of the essential 
fevers and of the plegmasiae, are in many instances preceded by, and are 
therefore, doubtless, in greater or less degree dependent on, hyperiemia of 
this organ. 

Difficult as it is to ascertain the state of the brain in many diseases in 
which it is involved, we may determine whether or not there is congestion 
in the young child by observing the anterior fontanel le. If it be elevated 
and tense in an acute disease, hypersemia is indicated. Now, it is often 
unusually prominent in fevers and inflammations, especially in their first 
stages, when cerebral symptoms are present. Its elevation, under such 
circumstances, is obviously coincident with cerebral congestion. 

The acute inflammations which are most likely to be attended by cere- 
bral congestion are those of the mucous surfaces and pneumonia. Severe 
coryza, tracheo-brouchitis, entero-colitis, and colitis, commencing suddenly 
with great febrile excitement, are frequently accompanied in their initial 
stage by active congestion of the cerebral vessels. Cases like the follow- 
ing, which I find in my note-book, are not infrequent. An infant four 
months old had been sick about two days with coryza and bronchitis, when 
I was called to see it; the pulse numbered 156; respiration 64; nursed, 
and was somewhat restless ; cough frequent and dry ; bowels moderately 
relaxed. The mucous membrane of the fauces was injected, and coarse 
mucous rales were present in the chest. The anterior fontanelle rose above 
the level of the cranium, and pulsated forcibly. Soon after convulsions 
occurred, which were relieved by appropriate measures, and on the follow- 



CAUSES. 339 

iug day the fontanelle had subsided. The patient gradually recovered 
without any other untoward symptom. 

Cerebral congestion and convulsions often mark the initial stage of 
active intestinal phlegmasise. This is especially true of dysentery. The 
little patient, perhaps from the very inception of the colitis, is drowsy; its 
surface hot ; pulse full and rapid. There is sudden and momentary start- 
ing or twitching of the limbs. The anterior fontanelle, if still open, is 
elevated, and it is not till the lapse of several hours that the cause of these 
symptoms is apparent from the bloody stools. 

The causes of passive congestion of the brain are very different from 
those of the active form. A common cause is obstruction in a sinus or 
vein by a fibrinous concretion, or by a tumor or abscess external to it. 

I have occasionally met cases in which this form of cerebral congestion 
appeared to be plainly referable to obstruction to the return of blood from 
the brain by the pressure of bronchial glands, enlarged by hyperplasia in 
tubercular disease, these bodies diminishing by external pressure the 
calibre of the venae innominatse or the descending vena cava. Rilliet and 
Barthez have called attention to such cases in the clinical history of tuber- 
cTulosis. The following case may be cited as an example ; it occurred in 
the infant's service of Charity Hospital, in this city, in April, 1866. 

An infant, about one year old, affected with tuberculosis, both bronchial 
and i^ulmonary, was observed, during the ten days preceding its death, to 
bore the pillow with its head almost constantly, so as to wear the hair from 
the occiput. This movement of the head was the only prominent cerebral 
symptom. Nothing abnormal was noticed in the appearance of the eyes, 
nor was the stomach irritable. A spasmodic cough and progressive emacia- 
tion attracted attention, but these were referable to the tubercular disease. 
At the autopsy we found the cerebral sinuses, veins, and capillaries greatly 
congested. On tracing the veins which return blood from the brain, an 
inflamed and enlarged bronchial gland was discovered in the angle formed 
by the convergence of the right and left venae innominatae. This gland, 
which contained but a single point of cheesy degeneration, had attained 
such a volume by proliferation of its cells that it pressed upon both ves- 
sels, so that it had obviously retarded the circulation in each, and given 
rise to the cerebral congestion. 

Passive congestion often occurs in the infant at birth, either from tedi- 
ousness of the labor or delay in the expulsion of the body after the birth 
of the head. If it is simple congestion, and not congestion with hiemor- 
rhage, it soon passes off. Passive congestion of the brain also occurs in 
severe paroxysms of hooping-cough, in which return of blood from this 
organ is temporarily retarded. All are familiar with the congestion which 
occurs in parts external to the cranium, from the severity of the cough ; 
producing epistaxis, extravasations under the conjunctiva, etc. The extra- 
cranial obviously indicates the presence and degree of cerebral congestion. 



340 CONGESTION OF BRAIN. 

Those who practice in malarious regions sometimes meet cases of dan- 
gerous passive congestion of the brain, the result of malaria, occurring 
especially in the cold stage of intermittent fever. In these cases the sur- 
face is pallid, its temperature reduced, and the pulse feeble. The blood, 
leaving the peripheral vessels, collects in undue quantity in the internal 
organs, producing congestion of the brain, as well as of the thoracic and 
abdominal viscera. In the child with malarious disease, in whom there 
is less vigor of constitution than in the adult, death not infrequently occurs 
in this passive congestion. Two such cases have occurred in my practice, 
although in this latitude the malarious maladies are mild in comparison 
with the type which they present in many parts of the United States. 

Symptoms. — The symptoms of active congestion of the brain are stupor, 
great heat of head, throbbing of carotids, restlessness when aroused, twitch- 
ing of the limbs, and perhaps convulsions. There is also sometimes in- 
tolerance of light, and the anterior fontanelle, if open, pulsates strongly. 
In PASSIVE congestion many of the symptoms are the same as in the active 
form. Stupor, twitching of the limbs, and fretful ness or irritability when 
the patient is disturbed, are common, ordinarily without increase of tem- 
perature ; the surface may, indeed, be cool, and the face is not flushed nor 
the eyes injected. The strong pulsation and elevation of tlie anterior fon- 
tanelle, so conspicuous in active congestion, are — the former always, the 
latter often — lacking. In both forms there is a tendency to constipation. 

In many cases the symptoms of congestion of the brain are associated 
with others which proceed directly from the cause of the congestion, but it 
is not difficult, unless in exceptional instances, to determine which are due 
to the congestion, and which to the antecedent and coexisting pathological 
state. 

Anatomical Characters. — In active congestion there is an excess of 
arterial blood in the brain and its membranes. The arteries, to their 
minutest branches, are seen to be full, presenting the bright hue of oxy- 
genated blood. In passive congestion the sinuses and veins are distended. 
The pia mater, choroid plexus, and the vessels of the brain, have a darker 
appearance than in active congestion. In both forms of congestion, if they 
continue for a little time, other anatomical changes occur. If there is 
great distension of the capillaries, these vessels are apt to give way, and 
we find here and there little patches of extravasated blood. In other cases 
the over-distension is relieved by the transudation of the serous portion of 
the blood through the coats of the vessels. The cephalo-rachidiau fluid is 
then found in excess external to the brain and in the ventricles. 

Prognosis. — The duration and the result of congestion of the brain de- 
pend, in great measure, on the nature of the cause. If the cause is trivial, 
as mental excitement, fatigue, exposure to heat, there is usually prompt 
relief if the condition of the patient is understood and properly treated. 
If the cause is general or constitutional, as one of the essential fevers or 



TREATMENT. 341 

hooping-cough, or if it is local, but its seat external to the cranium, the 
prognosis, so far as the congestion is concerned, is not unfavorable, if there 
is a timely and judicious use of remedies. The most unfavorable cases are 
those in which the cause is seated in the encephalon, and those in which 
there is some obstructive disease in the course of the circulation. Con- 
gestion occurring from a structural change within the cranium is, from 
the nature of the cause, without remedy, and ordinarily fatal. Obstruc- 
tive diseases of the circulatory system, wherever located, being for the 
most part permanent, give rise, as a rule, to incurable congestion. 

Congestion of the brain, if it is not relieved in a few hours, becomes less 
and less amenable to treatment. It soon passes beyond the resources of 
our art, and ends in coma ; it is seldom protracted beyond a few days. 
Extravasations of blood common in active congestion, and serous effusion 
common in the passive form, diminish the chances of a favorable result. 

Treatment.- — The indication for treatment in active congestion is plain. 
Measures should be employed which have a derivative effect from the brain. 
Unless there is an asthenic primary affection, in the course of which the 
congestion is developed, active purgation is required. A saline purgative 
is ordinarily preferable. If the stomach is irritable, there is no better 
purgative than calomel. In all cases of active congestion, whatever the 
cause, the bowels should be kept open. It is often better not to wait for 
the tardy action of a cathartic, but to give at once an enema of soap 
and water or salt and water. External derivative agents are also in- 
dicated. A warm mustard foot-bath, sinapisms to the back of the neck 
or chest, and to the feet, and cold applications to the head, are measures 
which should never be neglected. 

This treatment, if employed early, will relieve the congestion in a large 
proportion of cases ; but if there is no improvement, if the child is robust, 
and if the primary affection be such as does not contraindicate loss of 
blood, leeches should be applied to the temples or some part of the head. 
If after the lapse of some hours cerebral symptoms continue, apoplexy or 
serous effusion has probably occurred. Congestion is then no longer the 
prominent lesion, and it is proper to designate the disease by another 
name. 

The treatment appropriate to passive congestion is somewhat different ; 
cold applications to the head, and those of a derivative nature to the ex- 
tremities, are useful. As this form of the disease is not primary, but is 
dependent on some antecedent pathological state, it is evident that it can 
only be treated successfully by removing or obviating as far as possible 
the cause. But the nature of the various obstructions to the intracranial 
circulation is such that our ability to accomplish this end is very limited. 

If the cause is constitutional, or if it be some disease in the neck or 
chest, it may sometimes be partially or even wholly removed, but if seated 



342 INTRACRANIAL HEMORRHAGE. 

within the cranium it is beyond our control. In general, it may be said 
that depletion is not required or tolerated in passive congestion, and occa- 
sionally stimulants are needed. 



CHAPTEE VL 

INTRACRANIAL HAEMORRHAGE (MENINGEAL HAEMORRHAGE- 
CEREBRAL HAEMORRHAGE). 

HEMORRHAGE within the cranium is not very infrequent in infancy 
and childhood ; and there is no part of the encephalon, whether the 
meninges or brain, in which it does not sonaetimes occur. If the blood is 
extravasated upon the surface of the brain or between the meninges, the 
disease is designated by writers meningeal apoplexy ; if in the substance 
of the brain, cerebral apoplexy. Extravasation may also occur in one of 
the lateral ventricles. This may, for convenience, be described as a form 
of meningeal apoplexy. 

Causes. — Apoplexy is usually (there is an exception) preceded by con- 
gestion. If the congestion increases to a certain degree, the distended 
capillaries give way and extravasation of blood results. Therefore the 
causes of congestion which have been enumerated in the preceding article 
are, in great measure, those of apoplexy. Recent microscopic examina- 
tions have demonstrated that the corpuscular elements of the blood may 
escape from capillaries without rupture. While, therefore, it is probable 
that intracranial haemorrhage in early life commonly occurs from a rup- 
ture, its occasional occurrence through the walls of the capillaries must 
be admitted. 

Intracranial hsemorrhage is not infrequent in the new-born. It results 
in them from tediousness of the birth and severity of the labor-pains. 
At first there is extreme congestion of the meningeal and cerebral vessels 
corresponding with that of the scalp and face. This congestion continu- 
ing, soon ends in extravasation of blood. In some of these cases forceps 
have been used to effect the delivery, but it is doubtful whether the use of 
instruments matei'ially increases the congestion or the amount of extrava- 
sation. Certainly, in a large proportion of intracranial as well as supra- 
cranial haemorrhages of the new-born, instruments have not been used. 
An additional cause of the hsemorrhage is, in some instances, the use of 
ergot, which, by producing strong and continuous pains, interrupts the 
placental circulation and increases the congestion of the foetal veins and 
the capillaries. 



ANATOMICAL CHAEACTERS. 343 

In infants a few days old intracranial hsemorrhage may result from 
that rapid and fatal disease, tetanus infantum. The hsemorrhage is 
preceded by intense passive congestion, which the tetanic rigidity and 
spasms produce by obstructing respiration and circulation. Few cases of 
tetanus infantum occur without more or less extravasation of blood, 
either meningeal or cerebral. Another cause of this disease is obstruc- 
tion in the vessels which return the blood from the brain. The various 
structural changes which produce this obstruction, in different cases, have 
been sufficiently described in our remarks on cerebral congestion and 
thrombosis. 

The congestion which precedes hsemorrhage, when occurring under the 
conditions described above, is passive. 

Among the causes which produce hsemorrhage through the intermediate 
state of active congestion may be mentioned great mental excitement, of 
which M. Legendre relates a case, lengthened exposure to the sun's rays, 
an example of which Eilliet and Barthez have seen. It is also said that 
compression of the aorta by an enlarged liver or an abdominal tumor has 
sometimes produced meningeal or cerebral hsemorrhage, by causing an 
increased afflux of blood to the head. A very important cause to which 
I have not alluded, is that general state of the circulatory system which 
is designated by the term purpura hsemorrhagica. This sometimes results 
from the anti-hygienic conditions in which the child is placed. In other 
instances it results from some antecedent disease, protracted, debilitating, 
and which has produced a profound alteration in the state of the blood 
and the vessels. The capillaries become less firm and elastic, and easily 
give way, so that in such patients ecchymotic points are ordinarily found 
in different parts of the system. The diseases which occasionally end in 
this hsemorrhagic diathesis are numerous. I have known it to occur after 
measles, scarlet fever, and small-pox. It is also an occasional sequel of 
chronic diarrhoea, of intermittent and typhoid fevers, and of rachitis. 

Anatomical Characters. — Hsemorrhage in or upon the brain, in 
infancy and childhood, differs in important particulars from that occur- 
ring in adult life. In the adult, and more so as life advances, the arteries 
become less distensible and more brittle, so that when hsemorrhage occurs 
it is usually from one of these vessels. In early life, on the other hand, 
the blood does not ordinarily escape from an artery, but, as has been 
stated, from the capillaries. The extravasation is not, therefore, so rapid 
and violent, and is not attended with such laceration and injury of sur- 
rounding parts, in infancy and childhood, as at a subsequent age. In the 
adult the hsemorrhage commouly occurs in the substance of the brain. 
The flow of blood from the ruptured artery separates the brain-substance, 
producing a cavity in which a clot forms. This constitutes the usual form 
of apoplexy in the adult. In the first years of life, on the contrary, the 
extravasation is commonly from the meninges, and the symptoms to which 



344 INTHACRANIAL HAEMORRHAGE. 

the effused fluid gives rise are for the most part due to its mechanical 
effect. Cases of haemorrhage in the substance of the brain constitute a 
small minority, unless during the days immediately succeeding birth. In 
early life, therefore, on account of its greater frequency, meningeal haemor- 
rhage is a disease of more importance than cerebral, and its anatomical 
character should be carefully studied. 

In meningeal hcemorrhage the extravasation may be between the cranium 
and dura mater, upon the visceral layer of the arachnoid, in the meshes 
of the pia mater, or in a lateral ventricle, from rupture of the capillaries 
in the choroid plexus. Much the most common seat is external to the pia 
mater in the so-called cavity of the arachnoid ; the blood escaping in this 
situation spreads uniformly in all directions. It soon separates in two 
portions, the solid and liquid. The solid portion, or the clot, is free or but 
slightly attached to the adjacent membrane. The meninges in the vicinity 
of the extravasated blood preserve their normal appearance, or are but 
slightly injected ; the clot gradually becomes extended on all sides, so as 
to form a lamina at the seat of the extravasation, thinner at its circum- 
ference than centre, and at first of a dark-red color. The color gradually 
fades, and the lamina becoming smooth and polished, and at the same time 
more and more attenuated, finally resembles the arachnoid in appearance. 
Its diameter varies in different cases from a few lines to two or three or 
more inches. M. Tonnele relates two observations in which the adven- 
titious membrane extended over the superior surface of both hemispheres, 
and in one of them, also, over the falx cerebri. 

The extravasation may occur at any part of the surface of the brain, but 
its usual seat is the vertex. The next most frequent locality is the base of 
the brain. The subsequent history of the delicate membrane into which 
the clot is gradually transformed is interesting. It often extends so as to 
cover more space than was occupied by the extravasated blood, and its 
edges are then scarcely distinguishable, in consequence of their extreme 
tenuity, and their close resemblance to the arachnoid. The attachments of 
this membrane, so far as it forms any, are usually to the parietal surface 
of the arachnoid. Sometimes a portion of the membrane is attached, while 
the rest lies free, bathed on either side by the liquid portion of the blood 
which still remains from the extravasation. According to M. Legendre, 
in the most favorable cases, the serum is absorbed, and the membrane 
which has resulted from the clot, and which I have described, becomes in- 
timately adherent to the internal surface of the dura mater. It forms an 
integral part of this membrane, and there only remain a little thickening 
and increased opacity, indicating the seat of the extravasation. The health 
is fully re-established. 

But th.e result in other cases is as follows: The serum is not absorbed, 
and the newly-formed membrane, uniting at points with the inner surface 



CEREBRAL HEMORRHAGE. 345 

of the dura mater, or its arachnoidal covering, incloses the fluid so as to 
produce a circumscribed hydrocephalus. 

Sometimes there is only one cyst ; in other instances the membrane, 
especially if large, unites in such a way as to give rise to more cysts than 
one. The size of the cyst varies, according to the quantity of fluid, which 
may be only a few drachms or several ounces. Rilliet and Barthez report 
a case in which there w^as a pint of fluid lying over each hemisphere, there 
being two cysts. If the cranial bones are not united, so that they yield to 
the pressure, the size of the cranium is increased, and if the extravasation 
is confined to one side, an inequality results, and the symmetry of the head 
is destroyed. The fluid which causes the enlargement of the head in such 
cases, is in part the serum of the extravasated blood, and in part a subse- 
quent secretion. 

Various writers relate cases of ventricular haemorrhage. Valleix met it 
in an infant that died at the age of two days. In the Eclin. Jour, of Med. 
and Surg., October, 1831, an interesting case is related. A boy, nine years 
old, died of haemorrhage in both ventricles, and also at the base of the 
brain and in the spinal canal. In the Nursery and Child's Hospital of this 
city, the post-mortem examination was made of an infant who died at the 
age of one mouth. In the posterior cornu of the left lateral ventricle were 
two clots, elongated and black, one larger than the other. In the cor- 
responding cornu, on the opposite side, was a smaller clot. A similar 
post-mortem appearance was observed at the autopsy of a young infant in 
the infant service of Charity Hospital. A dark crescentic clot lay in each 
posterior cornu. The clot, if remaining a long time, undergoes degenera- 
tion. In the case of an adult, in which a year had elapsed after the 
extravasation, I found it to contain crystals of cholesterin and carbonate 
of lime. 

Cerebral HiEMORRHAGE, or haemorrhage in the substance of the brain, 
may occur at any time in infancy and childhood. The blood is sometimes 
extravasated in points, here and there, over the entire organ, or a part of 
the organ ; in other cases it is extravasated in one or perhaps two cavities, 
as in the ordinary form of apoplexy in the adult. In the first form of 
cerebral haemorrhage, or that in which the blood escapes from numerous 
points through the brain, there is evidently little laceration or injury of 
the organ. The brain-substance surrounding the haemorrhagic points some- 
times preserves the usual appearance. It is white and firm. In other 
cases it presents a reddish or yellowish appearance, and is softened to the 
depth of a line or two. If the haemorrhage occur in a cavity, as in apo- 
plexy of adults, the nerve-fibres are evidently torn and separated, and there 
is more or less compression of the surrounding brain-substance. Unless 
the disease is of long standing, the cavity contains a dark and soft clot 
bathed with serum, which has a reddish or a yellowish-red appearance. 
The brain in the immediate vicinity of the cavity is sometimes softened. 



346 CEREBRAL HAEMORRHAGE. 

Rilliet and Barthez state that they have seen eight cases of cerebral haemor- 
rhage of the capillary form ; ten cases in which the haemorrhage was in 
cavities ; and in two of the eighteen both forms were present. In five of 
those in which the form was capillary the disease was limited to portions 
of the brain, while in the remaining three the ha3morrhagic points were 
found in nearly every part of the brain. 

Apoplectic cavities are seldom seen in the cerebellum, and, whether the 
haemorrhage be capillary or in a cavity, there is, in most cases, as pre- 
viously stated, more or less congestion of the vessels of the brain. 

The proportion of cases of cerebral to other forms of haemorrhage is 
believed by some to be greater in the new-born than at any other period 
of life. Valleix relates four cases of intracranial hsemorrhage occurring 
at this age, two of which were cerebral, one ventricular, and in the other 
the extravasation was in the cavity of the arachnoid. Mignot has pub- 
lished eight cases occurring in the new-born, in two of which the hsemor- 
rhage was in cavities in the cerebrum ; in three, in the lateral ventricles ; 
and in three, external to the brain. If the same proportion be observed 
in other statistics, one in three of the cases of intracranial hsemorrhage 
occurring in the new-born is cerebral. 

Symptoms. — The symptoms in intracranial hsemorrhage are not uni- 
form ; they vary according to the seat as well as the quantity of the effused 
blood. In some cases the extravasation occurs without such symptoms as 
would direct attention to the brain. When the hsemorrhage occurs at the 
time of birth, in consequence of the strong and long-continued labor pains, 
the infant is often born apparently dead. This is due partly to the hemor- 
rhage, partly to the great congestion of the brain which precedes and 
accompanies the hsemorrhage. Resuscitation is gradual and diflBcult. The 
infant's features are livid, and perhaps swollen ; its respiration is gasping, 
and both pulse and respiration are slow. Its cry is feeble, with but slight 
movement of the facial muscles, and the lungs are but partially inflated ; 
the eyelids are closed, and the limbs almost motionless. By artificial 
respiration and by friction, the pulse and breathing may be rendered more 
frequent, but the latter remains irregular and gasping. Finally, the limbs 
grow cold, the surface, from a state of lividity, becomes pallid, and death 
occurs in profound coma. M. Cruveilhier made many observations at the 
" Maternity" in reference to the death of new-born infimts, and he believes 
that one-third of those who die in birth, at the full period, die of apoplexy. 
I have made post-mortem examinations in a few cases, when death had 
occurred from this cause, and in all the hsemorrhage was meningeal. One 
of these was born on the 30th of December, 1864. The birth was delayed 
by unusual projection of the promontory of the sacrum, so that finally 
the application of forceps was necessary. The infant was apparently still- 
born, but by persistent eflforts on the part of the physician who assisted, it 
was resuscitated so as to live several hours, though with constant embar- 



I 



SYMPTOMS. 347 

rassment of respiration and with lividity. At the autopsy a large ex- 
travasation of blood was found in the cavity of the arachnoid, over a con- 
siderable part of the convexity of the brain, and the substance of the brain 
was deeply congested. 

Apoplexy in the new-born does not always terminate fatally, or, when 
fatal, in the sudden manner which I have described. Valleix relates the 
case of an infant who died of pneumonia at the age of three and a half 
months. Its birth had been protracted and difficult, but was completed 
without the use of instruments. It had had during its entire life paralysis 
of the right side. At the autopsy a clot was found near the base of the 
right thalamus opticus, evidently existing from birth. Around the clot 
the brain was softened to the depth of some lines, and was of a bluish-red 
color. A very similar case is related by M. Vernois. An infant lived 
forty-nine days with paralysis of the left side, and died of pneumonia. At 
the autopsy a hsemorrhagic excavation in the process of cicatrization was 
found behind the right corpus striatum and the thalamus opticus. 

Intracranial hsemorrhage occurring from accidents of birth is generally 
attended by marked symptoms, such as have been described. But when 
it occurs subsequently to birth, whether in infancy or childhood, the symp- 
toms vary greatly in different cases, and are generally obscure. I will 
briefly state the symptoms which have been observed in both the cerebral 
and meningeal forms of this disease. First, the cerebral. Sedillot relates 
the case of a child seven and a half years old, whose bare head had been 
exposed several hours to the sun's rays. Suddenly, after a paroxysm of 
anger, it was seized with great pain, corresponding with the posterior and 
inferior fossae of the cranium. It uttered piercing cries, and died in a 
quarter of an hour. A clot was found in the right lobe of the cerebellum. 
Richard Quinn (Rilliet and Barthez) gives the history of a boy nine years 
old, who in playing wdth a hoop suddenly stopped, carried his hands to 
his head, and fell backwards unconscious. Three or four hours after- 
wards, when examined, he was found pale, surface cool, respii^ation slow 
and at times stertorous, pulse 50 to 60 per minute; the left arm was flexed; 
the left leg paralyzed ; the right leg and arm convulsed ; right pupil 
strongly dilated, the left contracted. He died seven hours after tlie com- 
mencement of the attack, and a large clot was found in the centrum ovale 
on the right side. 

Rilliet and Barthez relate the following case from Campbell. A boy 
with good previous health was suddenly seized about 7 a.m. with repeated 
vomiting, and in an hour and a half with violent convulsions ; he rolled his 
eyes and uttered inarticulate cries ; pulse frequent and hard ; pupils con- 
tracted ; trunk and lower extremities cool. In the afternoon he presented 
symptoms of compression of the brain, such as dilatation of the pupils, 
frequent and feeble pulse. Death occurred in the evening, and a luximor- 
rhagic cavity was found occupying the right middle lobe of the cerebrum. 



348 CEREBRAL HAEMORRHAGE. 

Guibert relates a case of extravasation in the superior part of tlie right 
hemisphere of the brain in a boy fourteen years old. The principal symp- 
toms were feebleness of the limbs, inability to walk, cephalalgia, involun- 
tary evacuations, fever, grinding the teeth, rigors severe and prolonged, 
lividity, loss of intellectual faculties, dilatation of the pupils, insensibility 
to light, stertorous respii-ation. Death occurred in about an hour. 

Rilliet and Barthez narrate the history of a girl two years old, who, 
after an attack of measles, was taken with convulsions accompanied with 
fever and prostration. The convulsive movements affected especially the 
eyes and upper extremities ; the right leg was immovable ; the left pupil 
dilated. These symptoms resulted from haemorrhage in the corpus striatum 
and opticus thalamus. The same authors relate also the case of a girl, 
seven years old, who died with a large apoplectic cavity in the left thalamus 
opticus. The symptoms were headache, convulsive movements, loss of con- 
sciousness, delirium, vomiting and constipation, convergent strabismus. 
These symptoms nearly disappeared, but in a few days the headache re- 
turned, with strabismus and a slight drawing of the face towards the left; 
on the twenty-seventh day there were some convulsive movements of the 
right eye, with paralysis of the arm. Finally contraction of the arras 
occurred, with acceleration of pulse, irregular breathing, dilated pupils, 
paralysis, and retraction of the head, followed by death on the forty-eighth 
day. 

These cases, and those from Valleix and Vernois, which have been re- 
lated in our remarks on haemorrhage of the new-born, are sufficient to show 
the character of the symptoms in that form of cerebral haemorrhage in 
which the extravasated blood forms a cavity in the interior of the brain. 

If the amount of extravasation is large, and the substance of the brain 
is much lacerated and compressed, death may occur almost immediately, 
and, therefore, without symptoms, or before it is possible to determine 
whether or not symptoms are present. If the disease is not so speedily 
fatal, the symptoms, as appears from the above cases, are headache, con- 
fusion of thought, or even insensibility, cries, sometimes piercing, cold ex- 
tremities, pallor, slow and perhaps stertorous respiration, convulsive move- 
ments followed by paralysis, or convulsions affecting one or more limbs, 
with paralysis of others, pupils contracted or dilated, sometimes one con- 
tracted and the other dilated, strabismus, rolling of eyes, vomiting. 

These symptoms have all been observed in different cases, but they are 
not all present in any one case. Those which are generally present, and 
on which we mainly rely for diagnosis, are headache, convulsive move- 
ments, paralysis, confusion of thought, irregularity in the pupils, and 
strabismus. 

In the CAPILLARY form of cerebral haemorrhage there is usually some 
complication, so that it is not easy to determine how far symptoms are due 
to the haemorrhage, and how far to the coexisting pathological state. 



SYMPTOMS. 349 

There are, indeed, but few published observations of capillary hsemor- 
rhage in the substance of the brain uncomplicated with meningeal haem- 
orrhage, haemorrhage in a cavity, or some other and distinct disease, but 
so far as I have been able to ascertain the symptoms referable to this form 
of extravasation, they are as follows : The child is drowsy ; fretful when dis- 
turbed ; it perhaps moans. There are sometimes slight convulsive move- 
ments and partial paralysis. If there is considerable extravasation, the 
respiration is irregular and sighing. Death occurs in coma, occasionally 
preceded by convulsions. Taupin relates the case of a child nine years 
old, who died Avith this form of hsemorrhage, accompanied by softening 
of the brain. The disease began at night, with delirium, agitation, and 
piercing cries. In the morning the patient lay in bed, drowsy, not com- 
plaining of pain, and not replying to questions; pupils dilated, and in- 
sensible to light ; left eye half open during sleep, and its axis changed ; 
eyebrows contracted ; face pale ; mouth open ; had no convulsions, but 
transient stiffening of the limbs, during which the thumbs were firmly 
compressed by the fingers; senses unimpaired, but the face drawn to the 
right ; deglutition difficult ; pulse small, irregular, and feeble ; respiration 
32, sighing. In the evening he had rigidity of the limbs and back, and, 
finally, was taken with general convulsions, in which he died at eleven 
o'clock. The hsemorrhagic points in this case were numerous. A boy 
five years old, whose case is described by Rilliet and Barthez, died of this 
disease, pneumonia, and white softening of the intestine. During the last 
five days there were cerebral symptoms, the chief of which Avere drowsi- 
ness, fretfulness when disturbed, and moaning without apparent cause. 
Another child, whose case is described by Rilliet and Barthez, died at the 
age of four years, with cerebral capillary hsemorrhage, accompanied by 
yellow softening. Six months before death he had general convulsions, 
followed by spasmodic movements of the left side. These subsided, but 
the left side remained feeble. 

In MENINGEAL HEMORRHAGE there are often convulsions, general or 
partial, in some patients tonic, in others clonic. When partial, the con- 
vulsive movements may only occur in the muscles of the face and eyes. 
With the spasmodic muscular action is a degree of drowsiness and irrita- 
bility. Paralysis, so common in the apoplexy of the adult, and not in- 
frequent, as we have seen, in the cerebral form of early life, is sometimes, 
but not ordinarily, present in meningeal hsemorrhage. Instead of paraly- 
sis, there are vomiting, some febrile action, thirst, and loss of appetite. 
The symptoms are different, however, according to the exact seat of the 
hsemorrhagic extravasations, and the duration of the disease. If the 
extravasation end in the formation of a cyst, the symptoms are those of 
hydrocephalus. The following condensed history of cases which I have 
selected as typical, will give us a clearer idea of the history and course of 



350 CEREBRAL HiEMOREHAGE. 

the various forms of meningeal haemorrhage than can be imparted by a 
narration of symptoms : 

M. Tonuele rehites the case of a child who was taken with fain tness and 
convulsive movements. On the following day the trunk and inferior ex- 
tremities became rigid ; deglutition was painful ; the pupils were largely 
dilated, immovable ; face pale ; pulse feeble and intermittent. Death 
occurred the same day. The dura mater was distended. A layer of 
coagulated blood, of great thickness, extended over the convexity of 
each hemisphere. The veins ramifying in the superior part of each 
hemisphere were distended with coagulated blood. The haemorrhage was 
in the meshes of the pia mater. Drs. Lombard and Panchard, of Geneva, 
relate a somewhat similar case. A child, thirteen months old, was con- 
valescing from inflammation of the bronchial and intestinal mucous sur- 
faces, when it was seized with general convulsions ; the mouth and eyes 
were open, and the eyes directed upwards ; pupils contracted ; pulse fre- 
quent and irregular. The convulsions abated somewhat, but soon reap- 
peared with violence. The patient became insensible, and died nineteen 
hours after the commencement of cerebi'al symptoms. The extravasated 
blood covered the upper surface of both hemispheres. From the above 
cases we see the symptoms and the course of meningeal hiiemorrhage, when 
the extravasation is so large that death speedily results. In protracted 
cases of meningeal haemorrhage, there is either a gradual disappearance of 
symptoms and return to health, or, circumscribed hydrocephalus occurring, 
the symptoms of that disease arise. 

Diagnosis. — It is evident, from what has been stated, that the diag- 
nosis of intracranial haemorrhage is attended with unusual difficulty, 
since the symptoms of this disease occur also in other and distinct patho- 
logical states. The history of the case, and especially the character of 
the cause, if ascertained, will aid in diagnosis. If there has been an 
obvious determination of blood to the brain, or some known obstruction 
to the return of blood from that oi-gan, the persistence of cerebral symp- 
toms would justify us in concluding that either serous or sanguineous 
effusion had supervened on a state of congestion. The points of differ- 
ential diagnosis between apoplexy and meningitis are the sudden and full 
development of symptoms in one case, the gradual commencement and 
gradual increase of symptoms in the other; differences also of symptoms in 
certain respects ; for example, as regards febrile reaction, constipation, etc. 

There is one symptom in cerebral haemorrhage which is of great diag- 
nostic value, namely, paralysis. Its presence affords strong evidence that 
there is extravasation of blood, and probably in a cavity in the substance 
of the brain. If the extravasation end in the formation of a cyst, the 
symptoms and appearances of hydrocephalus, which, after a time, arise, 
throw light on the nature of the disease. 

Prognosis. — There can be no doubt that many cases of intracranial 



TREATMENT. 351 

haemorrhage occur and terminate favorably without the nature of the dis- 
ease being suspected. In such cases the amount of extravasated blood is 
small or moderate. In several published cases in which the accui'acy of 
the diagnosis was shown by post-mortem examinations, the patients were 
convalescing from the haemorrhage when they succumbed to intercurrent 
diseases. If, however, the amount of extravasated blood is such as to give 
rise to those symptoms which have been described, the prognosis is unfa- 
vorable. Recurring convulsions, and persistent stupor from which it is 
difficult to arouse the patient, are unfavorable symptoms. If the convul- 
sions cease, and consciousness returns, even if there is paralysis, the result 
may be favorable. 

Treatment — The proper treatment in intracranial hseraorrhage de- 
pends on the state of the patient, the time which has elapsed since the ex- 
travasation, and the degree of it, as shown by the nature and severity of 
the symptoms. If, as is often the case, the patient is robust, and is visited 
soon after the commencement of the attack, cold applications should be 
made to the head, mustard to the back of the neck and perhaps chest, and 
derivation should be produced by mustard pediluvia. In many cases, 
especially in active congestion, it is advisable to apply leeches to the tem- 
ples, and the bowels should be opened by a stimulating enema. In active 
congestion, also, prompt purgation by salines or other cathartics, is some- 
times of great importance. The object of such treatment is to relieve con- 
gestion of the cerebral and meningeal vessels, and thereby prevent further 
extravasation of blood. If the congestion be active, the pulse continue 
full and frequent, and the face be flushed, it is proper in many cases to 
control the action of the heart by a sedative. For this purpose the tincture 
of aconite root may be given in doses of one drop to a child five years old, 
repeated in three hours if necessary, or veratrum viride may be used. If 
the stupor or convulsions continue after sufficient time has elapsed for the 
patient to receive the full benefit of the above remedies, more active coun- 
ter-irritation is required. Cantharidal collodion should be applied behind 
each ear. If the haemorrhage occur from passive congestion, or in a ca- 
chectic state of system, active depressing remedies should not be employed. 
External derivatives are of service, as well as cool applications to the head, 
and we should attempt, so far as possible, to remove the cause of the con- 
gestion and htemorrhage. If it depend on a cachectic state, tonic or other 
remedies calculated to relieve this state, are indicated. The haemorrhage 
from such a cause is apt to be in points in the substance of the brain, or in 
moderate quantity over the surface of this organ, and by a timely use of 
constitutional remedies possibly we may prevent further extravasation of 
blood and increase the chance of the patient's recovery. 

If a cyst result from the hiemorrhagic effusion, the treatment which is 
proper is that described in the chapter on Acquired Hydrocephalus. 



352 CONGENITAL HYDROCEPHALUS. 



CHAPTER VII. 

CONGENITAL HYDEOCEPHALUS. 

Congenital hydrocephalus consists in an excess of the cerebro-spinal 
fluid, lying either external to the brain, or more frequently in its interior. 
It is due to some vice in the development of the brain or its membranes, 
or to a pathological state occurring in them during intra-uterine life. This 
disease is ordinarily apparent from the symptoms and appearances at birth, 
but not always. Occasionally nothing unusual is observed in the shape of 
the head or aspect of the infant till after the lapse of some weeks, when 
the characteristic physiognomy begins to appear. In these cases the disease 
is still congenital, as there is every reason to believe that the abnormal 
state to which the excessive production of fluid is due existed from birth. 
In cases of arrested or partial development of the brain, as, for example, 
when a considerable portion of the hemispheres is absent, there is often an 
unusually large quantity of fluid which serves merely as a compensation 
for the lack of brain. I do not regard such cases as examples of hydro- 
cephalic disease, since the effect of the fluid is not injurious, but rather 
useful. I restrict the term congenital hydrocephalus to those cases in 
which the brain is complete, or, if incomplete, the quantity of fluid is 
more than sufficient to supply the deficiency. 

Anatomical Characters. — According to M. Breschet, the fluid in 
congenital hydrocephalus may be — 1st, between the dura mater and the 
cranium ; 2d, between the dura mater and the parietal arachnoid ; 3d, in 
the cavity of the arachnoid ; 4th, in the ventricles ; 5th, between the 
arachnoid and the brain. 

In a large majority of hydrocephalic patients the seat of the eff"asion is 
the ventricles. As the quantity of fluid increases, the pressure from with- 
in gradually unfolds the convolutions of the brain, at the same time pro- 
ducing expansion of the cranial arch. When the amount of fluid is con- 
siderable, and it becomes so in the course of a few weeks or months, the 
hemispheres are spread out in a thin lamina on either side, gradually de- 
creasing in thickness from the base of the cranium to the vertex, where 
the brain-substance is sometimes so thin as to be scarcely perceptible. 
Complete absence of brain in this situation, namely, at the vertex, even 
in extreme cases of expansion and flattening of the hemispheres from the 
pressure of the liquid is rare, though the brain-substance at this point is 
sometimes almost as thin as either of the membranes, so that the wall of 
the sac is translucent. The membranes which surround the brain do not 



ANATOMICAL, CHARACTERS. 



353 



usually undergo any alteration, except such as arises from the distension. 
The falx cerebri sometimes disappears, and sometimes the meninges pre- 
sent a whiter hue from maceration than in health. The distension also 
causes such an expansion of the pia mater that it becomes very thin, 
and in places scarcely visible, but its presence in every point can be 
demonstrated. 

The accompanying woodcut represents congenital hydrocephalus as it 
ordinarily occurs. I saw this infant when it was a few days old, and ex- 
amined it from time to time till its death. The parents are healthy and 
have other healthy children. This infant when nine days old began to 
have clonic convulsions of a mild form in the muscles of the face, neck, 
and limbs, which recurred almost daily till the age of six weeks, and 
sometimes every five or ten minutes. When the convulsions ceased in the 




sixth week, the head was observed to enlarge, and its excessive growth 
continued till death, which occurred at the age of seven months and one 
week. While the volume of the head progressively increased, the trunk 
and limbs emaciated. At death the occipito-frontal circumference of the 
head was nineteen and a half inches ; the vertical from auditory meatus 
to meatus thirteen and a half inches. 

The changes which the cranial bones undergo, both in their chemical 
character and in their shape, in hydrocephalic patients, if the amount of 
fluid is considerable, are interesting and remarkable. The base of the 
cranium undergoes little change, but those portions of the frontal, parietal, 
and occi{)ital bones which constitute the arch are expanded in all direc- 
tions, while they become much thinner. There is deficiency of lime in 



354 CONGENITAL H YDROCETH A L US. 

their constitution, so that their organic elements are greatly in excess. 
This renders them flexible and semi-transparent. Notwithstanding the 
expansion of the bones, there are usually interspaces between them, of 
greater or less size, according to the amount of fluid. 

The scalp, being stretched by the pressure within, becomes tense and 
thin, and is scantily covered with hair. The veins which ramify in it are 
unusually prominent and large, and the head is elastic on pressure, from the 
amount of liquid beneath. In the common form of congenital hydro- 
cephalus, namely, that' in which the liquid is in the interior of the brain, 
the shape of the orbital plates of the frontal bone is changed, so that the 
eyeballs have a downward direction. This change in the axis of the eyes 
occurs at an early period, and it continues through the entire disease, be- 
coming more and more marked as the quantity of liquid increases. If the 
amount be large, the lower part of the cornea is buried under the under 
eyelid, while the conjunctiva is visible between the cornea and the upper 
eyelid. The persistent downward direction of the eyes is characteristic of 
this disease, and, in connection with enlargement of the head, is an im- 
portant diagnostic sign. 

If we examine the interior of the cavity after the fluid is evacuated, we 
-will find at its base the parts which lie in the floor of the lateral ventri- 
cles, but changed in appearance in consequence of pressure. The coruua 
are enlarged, and the thalami optici and corpora striata are flattened. 
In the early stages of the disease, when the amount of fluid is small, there 
is probably no absorption or destruction of parts in the interior of the 
brain. The various portions of this organ retain nearly their normal 
relation to each other. As the quantity of fluid increases, the foramen 
of Monro, which unites the lateral ventricles, becomes enlarged, the septum 
lucidum which separates them disappears, and the two ventricles form a 
common cavity. In most fatal cases we find this single large cavity. The 
surface which surrounds the cavity occasionally presents a whitish or serai- 
opaque appearance, which has led to the belief, that at a period antece- 
dent to birth there was subacute inflammation of this surface, and hence 
the effusion. 

The bones of the face are ordinarily less developed than in healthy 
children of the same age, so that the disproportion between the head and 
face becomes a marked peculiarity. The shape of the forehead and face 
is nearly triangular. 

The foregoing remarks in reference to the anatomical characters of con- 
genital hydrocephalus refer in the main to cases which have continued for 
a considerable time, so that their characteristic features are well marked. 
In very young infants, in whom the disease is still recent, similar anatom- 
ical characters are present, but in less degree. 

Congenital hydrocephalus is often associated with other vices of con- 
formation, especially with spina bifida. The two, when coexisting, are 



ANATOMICAL CHARACTEES. 



355 



only parts of the same disease ; the large quantity of cerebro-spinal fluid 
preventing the spinal canal from closing during foetal development. 

The fluid in congenital hydrocephalus consists largely of water, in the 
proportion even of 99 parts in 100. In addition to this element, there are 
traces of albumen, chloride of sodium, phosphate, and carbonate of soda, 
and osmazome. 

I have had an opportunity to witness only one post-mortem examination 
in a case of congenital hydrocephalus in which the liquid was exterior to 
the brain. This case was under observation in the children's service of 
Charity Hospital in 1866. Full notes and measurements of the head were 
taken, which, unfortunately, were mislaid or lost. The infant had con- 
genital syphilis, and had a pallid, strumous appearance. The shape and. 
relative size of the head are seen in the accompanying figure, from a pho- 
tograph. While the whole head was enlarged, there was a relative excess 
of development in the part between and above the ears. The axis of the 
eyes was not at all changed, and the vision was good. The appearance 
corresponded so closely with descriptions of hypertrophy of the brain that 
this was supposed to be the anatomical state. Antisyphilitic treatment 
was employed, and the syphilitic eruptions had 
nearly disappeared, when diarrhoea supervened, ^' '^' 

followed by death. At the autopsy a quantity 
of transparent or light straw-colored liquid, 
estimated at six or seven ounces, was found 
exterior to the brain, in the great cavity of the 
arachnoid, lying mostly over the superior sur- 
face of the organ. There was no excess of 
liquid in the ventricles, and the brain, though 
of good size, was not abnormally large, nor 
did it possess the firmness which is present in 
true hypertrophy. 

All cases of congenital hydrocephalus may 
be embraced in two groups, namely, that in 

which the liquid is in the interior of the brain, and that in which it lies 
exterior to the organ. Liquid primarily in the arachnoidean cavity j)er- 
nieates the meshes of the pia mater, and lies in part underneath it, or this 
delicate membrane may be ruptured. Four of the groups, therefore, 
described by Breschet, may properly be reduced to one, namely, those 
groups in which the liquid lies under, between, or external to the men- 
inges. It is probable that some of the cases which led to Breschet's clas- 
sification were examples of acquired circumscribed hydrocephalus, the 
result of extravasation of blood. In this form of hydrocephalus, as is 
stated elsewhere, an adventitious membrane forms external to the li(juid, 
becoming in time thin and delicate, and often bearing a close resemblance 




356 CONGENITAL HYDROCEPHALUS. 

to the normal membrane (especially the arachnoid;, for which it is some- 
times mistaken. 

Symptoms. — If there is a considerable amount of hydrocephalic fluid 
prior to the birth of the child, so that the head is abnormally large, par- 
turition is seriously interfered with. The scalp and meninges may become 
ruptured by the severity of the pains so that the fluid escapes. If this 
does not occur, the labor is often necessarily instrumental. Whether the 
liqu'.d is present before birth or accumulates subsequently to it, the ten- 
dency is to an increase of the quantity, and a corresj^onding enlargement 
of the head. 

The digestive function in this disease is at first well performed. The 
infant nurses readily, and has its evacuations with the regularity of other 
children. Not many weeks, however, elapse, in the majority of cases, 
before defective nutrition is apparent. 

While the volume of the head increases, other parts are imperfectly 
nourished and stunted in their growth. Emaciation is common of the neck, 
trunk, and limbs, associated with progressive feebleness. In the last stages 
of this disease there is more or less vomiting, with constipation. If there 
was previously the ability to support the head, it is now lost, and the erect 
position is no longer possible. In marked cases, when there is great dis- 
proportion between the head and the rest of the system, there is frequently 
not even the ability to rotate the head on the pillow. As long as the cranial 
bones yield readily to the pressure from within, and there is no compression 
of the brain, the function of this organ is not seriously impaired. The 
child recognizes its mother or nurse, and it can be amused like other chil- 
dren, though easily fatigued. The state of the senses is different in dif- 
ferent cases, and sometimes at different stages of the same case. The sight 
and hearing in some are perfect, in others impaired ; while in others still 
they are good at first, but gradually become obscured and lost. It is said 
that the sense of smell may be perverted so that agreeable odors are un- 
pleasant, and vice versa. Many, reaching the age at which children begin 
to walk, cannot walk, or, if they do, it is with a tottering, unsteady gait, 

AVhen the liquid increases to that extent, and it usually does sooner or 
later, that the brain begins to be compressed, dangerous cerebral symp- 
toms arise. The child becomes drowsy, and takes less notice of objects. 
There are twitching of the limbs and finally convulsions. The pupils 
act feebly or irregularly by light, or one is more dilated than the other. 
Strabismus also occurs. As a fatal termination approaches convulsions 
occur, partial or general. These are soon succeeded by the last stage, 
that of coma, in which the patient expires. 

The following case, which I copy from my note-book, is an example of 
the common form of congenital hydrocephalus. It will give an idea of 
the ordinary course of this disease, and show the difficulty which we meet 
with in its treatment. Female, born November 9th, 1859, with the aid of 



SYMPTOMS. 357 

forceps. At birth the fontanelles were unusually large, the cranial bones 
separated, and the aspect in a marked degree hydrocephalic. She nursed 
at first, but, the mother's milk failing, she was afterwards bottle-fed. At 
the age of four months her head, which had increased faster than her 
general growth, measured from one auditory meatus to the other, over the 
vertex, seventeen inches; the occipito-frontal circumference, twenty-three 
inches. At this time she manifested considerable intelligence, being able 
to distinguish her mother from other persons, though the head was so large 
that it was necessary to support it constantly on a pillow. From the age 
of four to six months the operation of tapping was performed six times 
with a small hydrocele trocar, by Pi-of Stephen Smith, at a point near 
the coronal suture, and from an inch to an inch and a half from the 
sagittal. At each operation an amount of fluid varying from twelve 
ounces to one pint was removed, and the head then covered with strips 
of adhesive plaster, so as to form a complete cap. It was necessary, how- 
ever, within the twelve hours succeeding each operation, to loosen the 
dressing on account of either the occurrence of convulsions or symptoms 
premonitory of them. The head, within a week subsequently to each 
operation, regained its former size, and, as there was no permanent benefit, 
this treatment was discontinued. She finally died of entero-colitis at the 
age of ten months and five days. 

At the autopsy the distance from one auditory meatus to the other was 
twenty and a quarter inches ; the occipito-frontal circumference, twenty- 
six and a quarter inches. The anterior fontanelle measured antero-pos- 
teriorly four and three-fourths inches; transversely, seven and three-fourths 
inches. The parietal bones were separated from each other to the distance 
of two or three inches, and they measured in length nine and one-half 
inches. 

On opening the cranial cavity, seven pints, by measurement, of trans- 
parent fluid escaped, exposing a vast open space, at the bottom of which 
were the parts which constitute the floor of the ventricles, somewhat 
changed in shape, and from them, on either side, the hemisphere was 
spread in a lamina, so as to cover the internal surface of the crania] 
bones. The laminae near the base of the brain measured in thickness 
from half an inch to one inch, and they gradually became thinner on 
approaching the vertex, at which point the brain-substance was exceed- 
ingly thin, so as to be scarcely demonstrable. 

The brain had its normal vascularity and consistence, and the cerebel- 
lum, medulla oblongata, the base of the brain, and cranial nerves pre- 
sented their usual appearance. On folding the brain together, it had the 
size, shape, and aspect of this organ in its ordinary development. Noth- 
ing unusual was observed in the membranes except their great expansion. 
The above case corresponds in its general features witli most cases met in 
practice. 



358 CONGENITAL HYDROCEPHALUS. 

Diagnosis. — The ordiuaiy form of congenital hydrocephalus, that in 
which the liquid occupies the interior of the brain, can, in most cases, be 
readily diagnosticated. If there is only a moderate amount of liquid, it 
may be confounded with hypertrophy of the brain. In hydrocephalus 
there is commonly more rapid growth and greater expansion of the head ; 
moreover, the enlargement occurs equally on all sides, while in hyper- 
trophy, though all parts of the cranial vault are expanded, the enlarge- 
ment is more at the vertex than elsewhere. The sign, however, of greatest 
diagnostic value is the direction of the axis of the eyes. In hypertrophy 
the axis is unchanged, while in this form of hydrocephalus, although the 
amount of liquid may be small, the change of axis occurs which is de- 
scribed above. In rachitis the volume of the head is often considerably 
enlarged, due sometimes, in part at least, to a deposit of calcareous matter 
on the exterior of the cranial bones. The differential diagnosis is based 
on the shape of the head, round in one, square or with prominences in the 
other, on palpation, direction of the eyes, etc. The smaller the amount 
of liquid, the greater the liability to error of diagnosis ; but if the amount 
is inconsiderable and not increasing, little treatment is required, except 
hygienic and tonic, which is also proper in both hypertrophy and rachitis. 
If the liquid is exterior to the brain, as in the case represented on page 
355, diagnosis may be difficult, but such cases are infrequent. 

Prognosis. — This is unfavorable. The amount of liquid in congenital 
hydrocephalus, as already stated, commonly increases. The most favorable 
result is no increase, or but slight, in the quantity, while the natural growth 
of the infant continues, and thus the disproportion between the head and 
the rest of the system gradually disappears. This result is exceptional. 
Ordinarily, while the quantity of fluid increases, the nutrition of the body 
and limbs is more and more deficient. The patient, if not cut off by some 
intercurrent disease, finally succumbs with cerebral symptoms produced 
by pressure of the fluid. The majority of those affected with congenital 
hydrocephalus die in infancy, but some enter childhood, and occasionally 
one reaches even adult life. Cases of recovery have been reported, but if 
they were genuine, the disease was evidently mild, and the amount of liquid 
small or moderate. 

Treatment. — It is a proper question, in many cases, whether anything 
should be done to relieve the hydrocephalic infant besides attending to its 
general health. The anxiety of parents, however hopeless the nature of 
the case if left to itself, reported recoveries, and the fact that we have 
medicines which in many instances diminish the amount of liquid in the 
internal cavities, incline us to the use of therapeutic measures. 

We may attempt to diminish the quantity of fluid by the use of diuretics. 
Digitalis, squills, nitrate and acetate of potash, have been used. Probably 
the most efficient diuretic in these cases is iodide of potassium. This 
may be given in doses of one to two grains every two hours to an infant of 



ACQUIRED HYDROCEPHALUS. 359 

six months. Constipation, if present, should be relieved by an occasional 
purgative. If it is tolerated, we may partially prevent the expansion of 
the head by a close-fitting cap. For this purpose strips of adhesive plaster, 
about one-third of an inch in width, should be applied so as to cover the 
entire head. The proper way of applying these is as follows : First, one 
strip from each mastoid process to the outer part of the orbit on the oppo- 
site side ; secondly, from the back of the neck, along the longitudinal sinus, 
to the root of the nose ; thirdly, over the whole head, so that the different 
strips will cross each other at the vertex ; and, lastly, a strip long enough 
to pass three times around the head should be applied, passing above the 
eyebrows, the ears, and below the occipital protuberance. Too tight an 
application should be avoided, as it may give rise to convulsions or other 
cerebral symptoms. If the cap can be tolerated, and the general health 
is good, the prospect is more favorable ; but usually, from the increase in 
the quantity of fluid, it is necessary in a few days to remove or loosen the 
plasters in order to prevent convulsions. If this treatment is not success- 
ful, we may finally resort to tapping. The mode of performing this opera- 
tion has already been indicated in the case which I have detailed. No 
appreciable good result has followed the use of irritating or sorbefacient 
applications in this disease. Nutritious diet and attention to the general 
health are requisite. 



CHAPTER VIII. 

ACQUIRED HYDROCEPHALUS. 

Hydrocephalus, or dropsy of the brain, may also occur in those who 
at birth are well formed and free from disease. Pathologists call this ac- 
quired hydrocephalus. It is in nearly all cases the result of disease, which 
is located sometimes within the cranium, but often in other j)arts of the 
system. 

Causes. — The diseases within the cranium which most frequently pro- 
duce serous effusion are the meningeal inflammations, both simple and 
tubercular, tumors or other causes which obstruct the venous circulation, 
and hiBmorrhagic effusion ending in the formation of cysts. Prolonged 
passive congestion often ends in transudation of serum through the coats 
of the capillaries. Therefore, all those causes of congestion, except such as 
have a transient or momentary effect, may be regarded as causes of serous 
effusion. 

Among the diseases external to the cranium which produce serous effu- 
sion within or upon the brain, may be mentioned retropharyngeal abscess, 
tuberculization or inflammation of the bronchial glands, scarlet fever, 



360 ACQUIRED HYDROCEPHALUS. 

and certain affections of an exhausting nature, especially protracted diar- 
rhoeal maladies. In four cases which have fallen under my notice, the 
cause was enlarged tubercular bronchial glands, which, by pressure on the 
venffi innorainatse, so retarded the flow of blood from the brain as to cause 
congestion and effusion. The causative relation of these glands to cerebral 
congestion is more fully described in our remarks in reference to this dis- 
ease. 

Dropsy of the brain is the common result of protracted diarrhoeal affec- 
tions in infancy, whether entero-colitis or non-inflammatory diarrhoea. It 
is preceded and accompanied by passive congestion of the cerebral veins 
and sinuses, due in part to feebleness of circulation in consequence of the 
exhausted state of the patient, and in part to the wasting of the brain, 
which always gives rise to more or less passive congestion, unless in young 
infants, in whom the cranial bones become depressed and override each 
other. Dropsy of the brain resulting from scarlet fever, and that peculiar 
circumscribed dropsy which results from hi;emorrhagic eftusions, are de- 
scribed elsewhere. 

A few cases have been related by different observers, Abercrombie 
among others, in which dropsy of the brain seemed to be essential. Noth- 
ing abnormal was observed, with the exception of serous effusion. But 
the reports of such cases are, for the most part, meagre ; and, as Barrier 
has well said, we are not to accept such cases as examples of essential 
dropsy of the brain, unless the post-mortem inspection is so complete as to 
render it certain that there was no antecedent disease to which the dropsy 
was due. 

Anatomical Characters. — Acquired hydrocephalus usually occurs 
after the cranial bones are firmly united, and, therefore, the shape of the 
head is not materially altered. If it occur at an early age, before there 
is firm union, there may be expansion of the cranial arch, as we sometimes 
observe in the circumscribed hydrocephalus resulting from haemorrhage. 
The effusion in acquired hydrocephalus occurs over the surface of the 
brain, in the subarachnoid space, or in the lateral ventricles. In the 
dropsy of protracted diarrhoeal maladies, I have rarely failed to find the 
liquid over the whole superior surface of the brain as well as at its base. 

The quantity of fluid in this disease is not large. In the majority of 
cases it does not exceed four ounces, and is often much less. It is trans- 
parent, or it has a slightly yellowish tinge. The membranes of the brain 
sometimes present their normal appearance, but in other cases they are 
injected. The brain itself, in some cases, presents an injected appearance 
from passive congestion of the veins and sinuses ; but, in other cases, when 
there has been more or less compression of the brain, there is no more than 
the ordinary, or even less than the ordinary vascularity, and the convolu- 
tions are somewhat flattened. 

Symptoms. — The symptoms of the pathological state, which gives rise 



PROGNOSIS — TREATMENT. 361 

to the dropsy, precede and accompany those which are referable to the 
dropsy itself. The dropsy declares itself by symptoms which are alarm- 
ing from the first. 

In children old enough to speak, or manifest intelligence, there may be 
at first complaint of headache. The child is irritable, its mind confused 
or wandering at times, or there is actual delirium. After a time drowsi- 
ness occurs. The head seems too heavy for the body, and is buried in the 
pillow. In fatal cases the features become pallid, the pupils sluggish, and 
perception and consciousness are gradually lost. The child lies in pro- 
found sleep, which increases. There are now often convulsive movements, 
partial or general, and these soon end in coma, in which the patient dies. 

Prognosis.— Acquired hydrocephalus commonly ends unfavorably. 
The prognosis depends not only on the quantity of liquid, but on the na- 
ture of the cause. If the cause be venous obstruction within the cranium 
or thorax, as we have no means of removing it, death is inevitable. If it 
be an exhausting disease, as entero-colitis or scarlet fever, although the 
case is not absolutely hopeless, the prospect is still unfavorable. It is only 
favorable when the quantity of effused fluid is small, the system not much 
reduced, and the primary disease mild. When acquired hydrocephalus 
arises from meningeal apoplexy, the case is apt to be chronic. The symp- 
toms and termination of this form of the disease are very similar to those 
in congenital hydrocephalus. 

Treatment. — The treatment in acquired hydrocephalus must vary 
somewhat in different cases, according to the nature of the disease on which 
it depends. I shall indicate the treatment, in part at least, in the descrip- 
tion of these diseases. Occasionally the condition of the patient is such 
that there is little to encourage us in the employment of any remedial 
measures. In vigorous children, if acquired hydrocephalus occur in con- 
nection with symptoms which indicate too active a circulation, moderate 
abstraction of blood from the temples at an early period may be useful, 
but cases requiring such depletory measures are rare. These cases require 
cold applications to the head ; the bowels should be opened, and deriva- 
tives should be applied to the feet and back of the neck. 

If the congestion be of a passive character, as when the circulation is 
obstructed by tumors or otherwise, benefit may still be derived from, cold 
applications to the head, and derivatives to other parts. In most cases of 
suspected dropsy of the brain, unless the patient is in such a hopeless state 
that all treatment is obviously futile, vesication should be produced behind 
the cars. I prefer cantharidal collodion for this purpose. In addition to 
this treatment, diuretics should be employed, unless there is too great pros- 
tration, or the course of the disease is so rapid that no benefit can result 
in consequence of the tardy action of these agents. The best diuretics are 
the acetate of potash and iodide of potassium. 



362 MENINGITIS, SIMPLE AND TUBERCULAR. 



CHAPTER IX. 

MENINGITIS, SIMPLE AND TUBERCULAK. 

The most iuterestiug and important disease of the cerebro-spinal system 
in early life, is that which is now designated meningitis. It is not infre- 
quent. The mortuary statistics of this city show that it is the cause of 
death in from one in twenty-five to one in fifty of the entire number of 
deaths, the proportion varying somewhat in different years. 

In 1768, the attention of the profession was particularly called to this 
disease, by Dr. Whytt, of Edinburgh. This observer, and the pathologists 
succeeding him, forming their opinion of meningitis from its most promi- 
nent anatomical character, namely, serous effusion, believed it a dropsy. 
They accordingly designated it acute hydrocephalus. During the last 
thirty years the profession have come to regard the disease as inflamma- 
tory, and hence the name by which it is now known, and which is believed 
to express its true pathological character. 

Sometimes meningitis in children is an idiopathic disease. In other 
instances it occurs to those affected by tuberculosis, and in many, if not in 
all such patients, there are tubercles in or under the. meninges, which ex- 
cite the inflammation in the same manner as in the lungs they cause pneu- 
monitis or pleuritis. Therefore two forms of meningitis are recognized, 
namely, simple and tubercular. 

I have records of forty-five fatal cases of meningitis, some occurring in 
my private practice, and the remainder in institutions of this city with 
which I have been connected. Post-mortem examinations w^ere made and 
recorded in thirteen of them. Twenty-five were under the age of one year, 
of which fifteen were apparently well when the meningits commenced, be- 
longing for the most part to healthy families; three were feeble and cachec- 
tic, but apparently without tubercles; and five had miliary tubercles in 
various organs, as show'n by post-mortem examination. The condition of 
the other two was not recorded. 

Of the twenty who were over the age of one year, the majority, namely, 
thirteen, presented a decidedly cachectic or a strumous aspect before the 
meningitis occurred, and a considerable number had symptoms of pulmo- 
nary tubercles. These statistics, as far as they go, show that simple men- 
ingitis predominates under the age of one year, and I may add eighteen 
months, while over that age the tubercular form is in excess. 

The belief has prevailed in the profession, that tubercular meningitis 
does not occur in young infants. This idea is fallacious, although, as has 



MENINGITIS, SIMPLE AND TUBERCULAR. 363 

been stated, meningitis under the age of one year is more frequently inde- 
pendent of tubercles or the tubercular diathesis than associated with them. 
Bouchut, speaking in reference to tubercular meningitis, says : "Up to 
this period it was not believed that this disease existed in young children, 
for no mention is made of it in the works of Denis and Billard. Still its 
existence at this age is, nevertheless, incontestable. MM. de Blache, 
Guersant, Rilliet and Barthez, and Barrier have observed several ex- 
amples of it, and I have collected six cases of this disease in the practice 
of M. Trousseau. The youngest child was only three months old, and the 
eldest had arrived at the end of his second year. No statistics can be 
based on so small a number of facts ; the only value they have consists in 
their overruling an opinion falsely accredited in medical science." I have 
witnessed the post-mortem of five cases of tubercular meningitis occurring 
in children under the age of one year, as is seen from the above statistics, 
and the age of one of these was only four months. In two, perhaps I 
should say three, of the five the presence of tubercles in the meninges was 
not positively demonstrated ; but in all of the five cases miliary tubercles 
were present in the lungs and other organs, so that I did not hesitate to 
consider the meningeal inflammation of a tubercular character. 

In patients over the age of eighteen months, although the proportion of 
tubercular to simple cases is larger than under this age, the excess is not so 
great, according to my statistics, as the remarks of some observers w'ould 
lead us to suppose. There can be no accurate statistics of tubercular 
meningitis without careful post-mortem examination of the state of the 
brain and other organs in each supposed case, and this examination some- 
times shows the meningitis to be simple, when the symptoms and physical 
signs had indicated its tubercular character. As an example, may be men- 
tioned a case which occurred in the children's service of Charity Hospital, 
in March, 1868. This infant died at the age of twenty months, having 
had a cough of moderate severity at least three weeks before death, and 
symptoms of meningitis about four days. It was considerably wasted, and 
was supposed to have tuberculosis. At the autopsy, no tubercles were found 
in any part of the body, but parts of both lungs were hepatized. A fibrinous 
deposit, varying in thickness, was found over the pons Varolii, the optic 
commissure, along the fissures of Sylvius, over the superior surface of the 
anterior half and also upon the posterior lobe of each cerebral hemisphere. 
As a careful examination failed to discover any tubercles, the meningitis 
was considered simple. Those who make these examinations, failing to find 
tubercles in the lungs and other organs in which they usually occur, should 
examine the lymphatic glands, for cheesy glands may be the cause of the 
formation of tubercles in the meninges while the organs of the trunk remain 
unafiected. The presence of cheesy glands in the absence of visceral tuber- 
cles, and with granulations upon the meninges, small, covered with fibrin, 
and of a doubtful character, goes far towards establishing the tubercular na- 



364 MEXINGITIS, SIMPLE AND TUBERCULAR. 

tureof the meningitis. Tims in one such case which I examined tlie men- 
ingitis seemed to be due to cheesy bronchial glands, and I therefore con- 
sidered it tubercular. 

Age. — The following table gives the age in meningitis, simple and tuber- 
cular, in forty-two cases in my collection : 

Cases. Age. 

1 .... 2^ weeks. (Autopsy.) 

2 .... 2 months. 

20 ... . From 3 to 12 months. 

10 ... . "1 }-ear to 2 years. 

5 . . . . "2 years to 5 " 

4 . . . . Over 5 years. 

42 

Rilliet and Barthez have also published statistics of the age in meningitis. 
Their cases were observed chiefly in hospital practice, and the result is some- 
what different. 

In thirty-two cases of simple meningitis observed by these authors, eight 
were under the age of one year, six from two years to five, and eighteen 
over the age of five years. In ninety-eight cases of tubercular meningitis, 
there were two under the age of one year, fifty-one between the ages of one 
year and five, thirty -eight between the ages of five years and ten, and seven 
between ten and fifteen years. 

Anatomical Characters. — The dura mater in meningeal inflamma- 
tion is either not affected, or is aflfected secondarily. In many cases it re- 
tains its normal appearance, its internal surface remaining smooth and 
polished. In others it is more or less injected, and the surface is dim or 
lustreless. Ordinarily, also, the free surface of the visceral arachnoid con- 
tinues unchanged, but sometimes it becomes dry and even cloudy or opaque, 
especially where it covers those parts which are most intensely inflamed. 
Exudation rarely occurs upon this surface, however intense the inflamma- 
tion. Those who have had the most ample opportunities for observation 
record but few cases of it. 

In both forms of meningitis the inflammatory action commences in the 
pia mater, and is usually confined to this membrane. In its meshes, or 
underneath them, the lesions occur which characterize this malady, and 
its vessels are always greatly congested. Tubercular meningitis is most 
frequently basilar, or basilar chiefly and primarily, but extending also more 
or less along the sides of the hemispheres. The inflammation is ordinarily 
most intense around the pons Varolii, in the subarachnoid space, and along 
the fi.ssures of Sylvius. In simple meningitis the inflammation may also be 
at the base, but in other cases it is at the vertex. It is at the vertex when 
the cause is exposure to the sun's rays. In addition to the augmented vascu- 
larity of the pia mater, we find an effiision of serum, fibrin, and pus, the quan- 
tity and proportion of these elements varying greatly in diflfereut cases. 



ANATOMICAL CHARACTERS. 365 

The exudation of fibrin is greatest along the course of the vessels, and in 
the depressions between the convolutions, and the opacity is most marked 
in these situations. Pus, when present, is almost semi-solid, from the 
small proportion of liquor puris which it contains, even in recent cases. 
If the disease have continued several days, the liquor puris may be mostly 
absorbed, and the pus-cells becoming shrivelled, irregular, and aggregated, 
may resemble closely the cheesy transformation of tubercle-cells. 

The fibrinous exudation presents features of interest. It does not usually 
attain much thickness, but by its opacity it conceals from view the brain 
underneath. If it occur in the fissures of Sylvius, the antei'ior and middle 
lobes are united by it. It is usually infiltrated through the substance of 
the pia mater. Sometimes little masses of variable size, often not as large 
as a pin's head, appear at the point of inflammation. These masses are 
firm, of a whitish color, or a light yellow, and their number varies in dif- 
ferent cases. They consist of a firm, homogeneous substance, containing 
granular matter, and cells which often bear a close resemblance to tubercle- 
corpuscles, but are distinct. These corpuscular bodies are plastic nuclei 
or plastic cells, often shrunken. It is seen, then, that there are two morbid 
products which may be mistaken for tubercle : one, pus which has been in 
great measure deprived of its liquid element; the other, plastic nuclei 
collected in little bodies, so as to resemble the ordinary form of crude 
tubercle. I once carried to one of the best microscopists and pathologists 
of this city some of the exudation from a case of meningitis, the cel- 
lular element in which could not readily be distinguished from shrunken 
tubercle-corpuscles. The exudation was from a child two years and eight 
months old, with good health previously to the meningitis ; without tuber- 
cles in any part of the body, with pai-ents healthy, and with no predisposi- 
tion to tubercular disease. This microscopist, not knowing the history of 
the case, or character of the family, and ignorant, like all of us at that 
time, of the true tubercle-cell, pronounced the exudation tubercular after 
a careful examination with the microscope. Bouchut says: "The whitish 
miliary granulations which are observed on the surface of the pia mater 
have a certain consistency and tenacity which render them difficult to tear 
with the needles used for tlie preparation for the microscope. These bodies 
are formed : 1. Of fibro-plastic elements, whether nuclei or fusiform fibres; 
oval-shaped cells are generally present, but not always. The nuclei are 
oval or spherical, generally very small — that is to say, they hardly exceed 
in diameter 0.008 mm. to 0.009 mm. The presence of these little spherical 
nuclei must be insisted on, because, with a less power than 550 diameters, 
it would be sometimes impossible to establish the differences which separate 
them from the elements of tubercle ; the fusiform fibres are small and rare. 
2. There exists a considerable quantity of amorphous homogeneous matter, 
in which minute granulations are scattered ; it is very dense, and keeps the 
other elements strongly united together, so that it is difficult to isolate 



366 MENINGITIS, SIMPLE AND TUBERCULAR. 

them completely. 3. Vessels are very rarely observed ; the fibres of cel- 
lular tissue are also rare, or altogether wantiug." 

There being two microscopic elements which are distinct from tubercular 
formations, but are liable to be mistaken for them, namely, shrivelled pus- 
cells and plastic nuclei, more or less altered, it is seen, in part at least, 
why the older writers, and some of a more recent date, either hold that all 
meningitis is tubercular, or that there are comparatively few cases of the 
simple form. 

On the other hand, there are cases of true tubercuhxr meningitis which, 
even with a pretty careful microscopic examination, might be, and prob- 
ably often have been, regarded as simple. In order to a better under- 
standing of this subject, I may be permitted to repeat certain facts already 
stated in the article on tuberculosis. The views of pathologists in reference 
to what is the primary form of tubercle, and what is and what is not tuber- 
cular matter, have recently undergone a great change. It is now believed 
that the tubercle-cell is a round, pale, slightly granular cell, identical in 
appearance with the normal cell of the lymphatic glands, being in the 
average somewhat smaller than the white corpuscle of the blood ; that it 
is produced mainly from the nuclei of the connective tissue by prolifera- 
tion ; that it is vitalized like other cells, and, of course, has functional 
activity ; that the true, the living cell, is found only in the so-called gray, 
semi-transparent tubercle. It is furthermore believed, that what has here- 
tofore been considered the tubercle-cell, namely, the irregular, sometimes 
angular, sometimes oval cell — without, indeed, any typical form — may be 
a dead, shrivelled, and altered tubercle-cell, or a dead, shrivelled, and 
altered pus or other cell. If, therefore, such cells are found in the meshes 
of the pia mater, we cannot determine from the microscope their true 
character. We can only form our opinion in reference to their nature 
from concomitant circumstances, or from discovering in connection with 
them the true tubercle-cell. Those products which have been designated 
crude tubercle and tubercular infiltration, contain these shrivelled cells, 
or shrivelled nuclei; and they may have a tubercular origin, or, on the 
other hand, an inflammatory origin, witliout either the tubercular product 
or diathesis. 

In the tuberculosis of young children I have found, in a large propor- 
tion of cases in which I have had an opportunity to make post-mortem 
examinations, miliary tubercles disseminated through the lungs, and per- 
haps other organs, in small masses, many of them' not larger than a pin's 
head, and some occurring as mere specks scarcely visible. These minute 
tubercular formations have ordinarily been semi-transparent, and some- 
times even transparent like minute drops of water, and containing the 
true and unchanged tubercle-cell. Now if in such a case meningitis 
occur, we may find the tubercle-cell in or with the fibrin at the base of 
the brain. But failure to find it, even with protracted microscopic exami- 



ANATOMICAL CHARACTERS. 367 

nation, does not j)rove its absence from this locality, for I consider it 
almost impossible to discover in the midst of the fibrinous exudation such 
minute points of tubercular matter as are seen in the lungs, liver, or else- 
where. In view of these facts, I know no better rule for the practitioner, 
who cannot command the time for thorough microscopic examinations, 
than to consider as tubercular all cases of meningitis in which tubercles 
or cheesy glands are observed, in whatever part of the system, and con- 
sider as examples of simple meningitis all those cases in which no tubercles 
are apparent in the meninges or in any other organ of the trunk. 

The pia mater is often firmly adherent to the brain at the seat of in- 
flammation, so that on raising it a portion of the brain may be detached 
and removed with it. The extent of the inflammation varies much in 
different cases. There may in extreme cases be pretty general inflam- 
mation of the pia mater. In cases of such extensive meningitis, the 
symptoms are apt to be severe and the course of the disease rapid. Thus, 
in the month of April, 1866, a girl eleven years of age, in the Protestant 
Episcopal Orphan Asylum of this city, had complained occasionally of 
dizziness, but was otherwise in good health, cheerful, and with excellent 
appetite, till Thursday, when she was affected with vertigo, more persist- 
ent than previously, and with headache. At 2 p.m. on the following day 
she was seized with general convulsions, and continued insensible or nearly 
so, with occasional convulsive movements, till Monday, when she died 
comatose. The pia mater at the vertex, sides, and base of the brain had 
a cloudy appearance, and underneath it, in places, was a thick creamy 
substance in small quantity, which, examined by the microscope, proved 
to be pus, the largest amount being near the pons Varolii. There was no 
tubercle under the meninges or elsewhere, and no appreciable fibrinous 
exudation. The inflammation in this case was obviously intense. The 
only additional lesions noticed were moderate congestion of the brain 
and an increase in the quantity of the cerebro-spinal fluid. 

If the disease is protracted three or four weeks, which is rare, or even 
less time, the exuded substance may undergo further changes, such as 
occur in simple exudations in other parts of the system. Thus, on the 
30th of April, 1860, we made the post-mortem examination of an infant 
at the Nursery and Child's Hospital, who had symptoms of cerebral dis- 
ease, it was stated, for several weeks, but the exact time was not ascer- 
tained. Prominent among the symptoms referable to the cerebro-spinal 
system towards the close of life were the hydrocephalic cry and rigidity 
of the neck. The appearance at the autopsy was remarksible. The an- 
terior half of the brain was com])letely incased in a deposit which had 
nearly the appearance of lard. It filled the fissures of Sylvius, and 
appeared slightly on the anterior aspect of the cerebellum. Examined 
under the microscope, this substance was found to contain numerous cells, 
among which could be distinguished some resembling pus-cells, but nearly 



368 MENINGITIS, SIMPLE AND TUBERCULAR. 

all had undergoue more or less fatty degeneratiou. Here and there was 
seen a large cell contaiuiug numerous small oil-globules, the compound 
granular cell of pathologists. 

The brain itself in meningitis is usually injected. On making an in- 
cision through it, red points are seen upon the cut surface, which indicate 
the seat of the congested vessels. The inflammation rai'ely extends to the 
walls of the ventricles, but the choroid plexus is injected. In exceptional 
instances pus or fibrin is found in the lateral ventricles. In the infant, 
two and a half weeks old, whose case has already been alluded to, about 
two ounces of purulent fluid escaped on opening the left ventricle. A 
small amount of liquid of a similar character w^as contained in the right 
ventricle. The distension of the lateral ventricles with serum is one of 
the common results of meningitis. This fluid is clear or straw-colored, or 
it is turbid in consequence of being mixed more or less with the softened 
brain-substance. The quantity does not exceed two, three, or four ounces, 
and is often not more than one ounce or an ounce and a half. The dis- 
tension of the two ventricles is ordinarily uniform, as they are united by 
the foramen of Monro, but now and then one ventricle is found more dis- 
tended than the other. If there is considerable eff'usion, the brain is 
compressed and the convolutions have a flattened appearance, unless the 
cranial bones are still separated so as to yield to the pressure. If the 
sutures and fontanelles are open the cranial arch is expanded, sometimes 
quite perceptibly to the eye. From the same cause the anterior fonta- 
nelle, if open, is elevated. The foramen of Monro is enlarged according 
to the amount of eff'usion, and the portions of the brain which separate 
the ventricles are sometimes lacerated. In many cases the cerebral sub- 
stance surrounding the lateral ventricles is softened. The softening is 
found in all degrees, from the least appreciable deviation from the normal 
consistence to a state of diffluence so that the brain presents the appear- 
ance of cream. Hypotheses have been advanced to explain the cause of 
this change in consistence, which are not entirely satisfactory. Whatever 
the explanation, the fact is attested by all observers, though there are 
exceptional cases. Thus Dr. West has records of the condition of the 
brain in fifty-nine cases, in thirty-seven of which there was considerable 
softening, and in the remaining twenty-two the consistence was normal. 

Causes. — The causes of simple meningitis are not fully ascertained. 
Active cerebral congestion, frequently occurring, is probably a common 
direct cause. I have known the inflammation in at least three instances 
to occur in infants from four to eight months old, who, a month or six 
weeks previously, had severe and protracted attacks of bronchitis. The 
disappearance of eruptions upon the scalp prior to the commencement of 
the inflammation is a fact often observed. I have noticed this before the 
commencement of simple meningitis, as well as before meningitis, if not 
tubercular, at least occurring in a decidedly scrofulous state of system. I 



SYMPTOMS. 369 

have already alluded to a case in which the inflammation, occurring in 
the pia mater at the vertex, apparently resulted from frequent exposure 
in the months of August and September bareheaded to the sun's rays. 

The cause of tubercular meningitis need not detain us. It is sufficiently 
dwelt upon in the foregoing pages. 

Premonitory Stage. — Meningitis is usually preceded by symptoms 
which, if rightly interpreted, are of the greatest value. In most cases of 
both the simple and tubercular forms, which I have seen, there was a pro- 
dromic period, varying from a few days to as many weeks. The symptoms 
of this period are obscure, and are apt to be mistaken for those of other 
and distinct affections. 

The child in whom meningitis is approaching loses his accustomed viva- 
city and cheerfulness. He has a melancholy and subdued appearance, 
being quiet for a few minutes and then fretful, without apparent cause. 
He can sometimes be amused by his playthings or companions for a bi'ief 
period, Avhen he turns from them witli evident displeasure. Unexpected 
and loud noises and bright lights are evidently painful. If old enough to 
describe his sensations, he complains of transient dizziness, and at other 
times of headache. His ill-humor, if his wishes are not immediately grati- 
fied, or if they are denied, is often scarcely endurable on the part of friends 
who are ignorant of the cause. There is great difference, however, in dif- 
ferent cases, as regards this symptom. Some are inclined to be taciturn 
and quiet, while others are almost constantly fretting. The appetite is 
capricious ; at one time it is pretty good, at another it is poor or even 
entirely lost. The patient may take a few mouthfuls of food, or, if an 
infiant, nurse for a moment, when his hunger appears satisfied, and he will 
take nothing more. The bowels are regular or inclined to constipation. 
The pulse is natural, or it has times of acceleration, especially in the latter 
part of the day and towards the close of the premonitory stage. The dura- 
tion of this stage is very different in different cases. Upon an average it 
is perhaps about two weeks, but it is often longer. In tubercular menin- 
gitis the symptoms, both during the inflammation and previously, are apt 
to be complicated by those which arise from tubercles in other parts of the 
system. 

Unless the prodromic period is of short duration, the effect of imperfect 
nutrition is obvious before it closes. The flesh becomes soft and flabby, 
or there is actual emaciation, though generally slight. The patient loses 
his strength, becoming less able to stand or to walk, and more easily 
fatigued. Occasionally, especially in the simple form, premonitory symp- 
toms are absent, or are slight and of short duration. 

Symptoms. — Dr. Whytt, living in the last century, when the tendency 
was towards refinement rather than simplicity in classification, divided 
meningitis into three stages, according to the symptoms,, especially the pulse. 
Many subsequent writers, following Whytt's example, have recognized 

24 



370 MENINGITIS, SIMPLE AND TUBERCULAR. 

three stages, based uot upon the anatomical characters of the disease, but 
upon the succession of symptoms. Such division of meningitis is in great 
measure arbitrary, since in one case the same symptom occurs at an 
earlier period than in another. 

When the premonitoiy stage has passed, and inflammation is developed, 
some of the symptoms which were previously present remain and are in- 
tensified, and other new and more characteristic symptoms appear. There 
are now fewer intervals of apparent improvement. The child is quiet, 
often lying with its eyes shut. If aroused, he has a wild expression of the 
face, and is irritated by attempts to engage his attention or amuse him. 
He rarely smiles, or takes his playthings, or he notices them for a moment, 
■when he turns away with disgust. During sleep there is often at first a 
placid expressicm of countenance, but when aroused he has the aspect of 
real sickness ; the eyebrows are sometimes contracted, as if from headache ; 
the features wear a melancholy look, and are turned away to avoid the 
gaze of the observer or to shun the light. If the anterior fontanelle is 
open, it is observed to be prominent and pulsating forcibly. If conscious- 
ness is not lost, and the patient is of sufficient age, he complains of head- 
ache, or of pain in some part of the body. The tongue is moist, and 
covered with a light fur; the appetite is lost or poor ; there is seldom much 
thirst ; more or less nausea and constipation ai-e present. As the inflam- 
mation continues, and usually within three or four days from its com- 
mencement, symptoms arise which dispel all doubts, if there were any, as 
to the nature of the disease. The vital powers are now evidently begin- 
ning to yield. The surface generally is more pallid, and there is the 
curious phenomenon of the sudden appearance, and, after some minutes, 
disappearance, of spots or patches, or even streaks of active congestion 
upon the face, forehead, or the ears. These, having a bright red color, 
contrast strongly with the general pallor. Ordinarily they are irregularly 
circular or oval, and from one inch to an inch and a half in diameter. A 
red spot or streak is also produced if the finger is pressed upon the surface 
or drawn forcibly across it. It continues a few minutes and then grad- 
ually fades. Trousseau calls attention to this fact as a diagnostic sign. 

Another curious phenomenon is the variation in temperature. The face 
and limbs at one time feel quite cool, and after some minutes, without any 
excitement or other appreciable cause, the temperature rises, so that the 
surface is warm to the touch. 

Consciousness, in severe cases, may be lost at an early pei'iod. On the 
other hand, I have known it iu a case of moderate severity to remain, 
though partially obscured,, till Avithin twenty -four or thirty-six hours of 
death. The patient will usually open his mouth for drinks, which are 
placed to his lips, when there is no other evidence of intelligence, and when 
sight and hearing are evidently lost. 

The loss of the senses constitutes an interesting but melancholy feature 



SYMPTOMS. 371 

of the disease. Among the first unequivocal symptoms, and frequently 
the very first, are such as pertain to the eye. This organ should be watched 
from day to day when the diagnosis is uncertain. Deviation from its nor- 
mal state affords evidence of meningitis. The pupils ai-e seen to dilate or 
contract sluggishly by variations in the intensity of the light, or they are 
not of the same size with those of another individual to whom the same 
amount of light is admitted. Sometimes the first perceptible deviation 
from the normal state is an inequality in the size of the pupils ; while in 
others oscillation of the iris is observed. At a later stage, not generally 
till convulsions have occurred, the parallelism of the eyes is lost, and in 
most patients they have an upward direction. After effusion has occurred, 
the pupils are commonly dilated. As death approaches, the eyes become 
bleared, and a puriform secretion collects in the inner angle of the eye and 
between the eyelids. This secretion is not abundant, but it is sometimes 
suffi^cient to unite the lids. The sense of hearing is probably lost as soon, 
or nearly as soon, as that of sight, but the sense of touch continues longer. 
The tongue is covered with a moist fur, unless near the close of life, when 
it is sometimes dry. The appetite is gradually lost, but often drinks are 
taken with apparent relish, even Avheu there is no other evidence of con- 
sciousness. There are two symptoms f)ertaining to the digestive system 
which are rarely absent, and which possess great diagnostic value ; one is 
vomiting, the other constipation. In some patients, irritability of stomach 
begins at so early a period that it is really prodromic ; it is rarely absent. 
Barrier collected the records of eighty patients with meningitis, and in 
seveiity-five of these this symptom was present. It is due to the intimate 
relation existing between the stomach and brain, through the ganglionic 
system of nerves. The vomiting occurs without effort, and usually at inter- 
vals, for several days. It is a sudden ejection of the contents of the stom- 
ach, apparently without preceding or subsequent nausea. It contrasts, 
therefore, with the vomiting due to an emetic, which is attended by dis- 
tressing symptoms. With some it occurs frequently, with others not more 
than two or three times daily. Commencing in the first stages of menin- 
gitis, or even prior to it, it occurs less often as the drowsiness becomes more 
profound, and finally ceases. Constipation is also present, usually from 
the commencement of the meningitis. It is one of the most constant and 
persistent symptoms, continuing through the entire sickness, unless relieved 
by medicine, or unless there is a coexisting diarrhoeal affection. Often, 
when diarrhoea precedes the meningitis, it ceases the moment the latter 
commences. The constipation in this disease is easily overcome by purga- 
tives. Several writers speak of retraction of the abdomen as a sign of 
meningitis. A hollow or sunken appearance of the abdomen, according 
to Golis, aids in distinguishing meningitis from fever. The anterior ab- 
dominal wall approaches the spine, so that the pulsations of the abdominal 
aoi'ta are distinctly felt. Rilliet and Barthez, who have rarely observed 



372 MENINGITIS, SIMPLE AND TUBERCULAR. 

this retraction except in cerebral diseases, attribute it to the state of the 
intestines rather than to the action of the abdominal muscles. 

The pulse in the first stages of meningitis is accelerated, or it is nearly 
natural during certain hours and afterwards accelerated. When the dis- 
ease has continued a few days, often not more than three or four, the pulse 
undergoes a marked change. It becomes slower and at the same time 
irregular. The irregularity usually consists in an intermittence of the pulse 
after each six or eight beats. Sometimes the force of the pulse varies, so 
that a feeble pulsation is succeeded by one of greater volume and strength. 
The decrease in the frequency of the pulse cannot fail to arrest attention. 
From 110 or 120 beats per minute in the first stage of the inflammation it 
often descends to a frequency even less than the normal adult pulse. At 
an advanced period, as death approaches, the pulse again becomes accele- 
rated and feeble. 

The change in respiration is as decided as that of the pulse. In the be- 
ginning of the meningitis respiration is sometimes moderately accelerated, 
but in other cases it is natural. When the disease has continued a few 
days, the time usually varying from three or four to more than a week, a 
marked alteration occurs in the respiratory movements. Their rhythm, like 
that of the pulse, is disturbed. The breathing is irregular, intermittent, 
and accompanied by sighs. This change in pulse and respiration corre- 
sponds with the loss of consciousness, and shows that the brain is becoming 
seriously involved. 

When the pulse and respiration undergo the changes which have been 
described, another prominent and grave cerebral symptom is often present, 
namely, convulsions. Its occurrence diminishes greatly the prospect of a 
favorable issue. The severity and extent of the convulsive movements 
vary in diflferent cases. They may be partial or general. Their duration 
is often bi'ief, but they recur three or four times through the day. They 
are preceded by cephalalgia in those old enougli to express their sensations', 
and often by drowsiness. Each convulsive attack ends in still greater 
drowsiness. 

With this group of symptoms another should be mentioned. I refer to 
the hydrocephalic cry. At intervals the patient, without being disturbed, 
and without any change in symptoms, utters a scream or sharp cry, and 
immediately relapses into his former state. This cry is more common in the 
commencement of the meningitis than subsequently, and in some it is absent 
or is not a marked symptom. The glandular system participates in the gen- 
eral loss or derangement of function. Tears are seldom shed, even when 
the child is much irritated, and the urinary secretion is greatly diminished. 
The small amount of urine passed sustains an important relation to the 
progress of the disease and the therapeutics. 

The patient usually lingers several days after the pulse and respiration 
are changed in the manner stated. The drowsiness becomes more pro- 



SYMPTOMS. 373 

found, the vomiting ceases, as well as the convulsive attacks, and sensation 
and consciousness are entirely lost. But even in this state, if nutriment 
and stimulants are administered with regularity, the child often lives sev- 
eral days longer than the friends believed to be possible. At length in- 
creasing feebleness and rapidity of pulse and coldness of the face and limbs 
indicate the near approach of death, which occurs in a state of coma. 

The symptoms described above are such as occur in ordinary cases of 
meningitis, and in the order which I have indicated. But he will be dis- 
appointed who expects that the above description will apply to all cases. 

Meningitis may be so violent and rapid that both the character and suc- 
cession of symptoms are different from those which have been stated. 
Thus, I have related the case of a girl, who, with no prodromic symptoms 
excepting occasional dizziness and slight headache, was taken sick on 
Thursday, had convulsions on Friday, and from this time continued either 
in convulsions or coma till her death on Monday. Again, even in cases of 
the usual duration and anatomical character, some of the most prominent 
symptoms upon which we rely for diagnosis may be lacking. The follow- 
ing was a case of this kind : 

Case. — On the 5th of April, 1862, I was asked to see a boy two years 
and eight months old, of healthy parentage, and who, during the preced- 
ing year, had been in uniform good health, but previously had had two 
or three severe attacks of sickness. His head was unusually large, and 
whenever much indisposed he often had symptoms premonitory of convul- 
sions, which were always, however, prevented. 

One night, in the latter part of March, his parents noticed that his sleep 
was restless, but on the following day he seemed entirely well, and the 
restlessness at night was attributed to a late and hearty supper. On suc- 
ceeding nights, however, he was restless, and, when questioned, complained 
of pain in the abdomen. In a few days he was observed to be drooping 
in the daytime, and his appetite was not quite so good as previously. He 
had continued in this way about a week when my first visit was made. 

The abdominal pain had at this time become more constant, but was never 
severe or accompanied by moaning. When asked where he felt sick, he 
placed his hand upon the epigastrium, pressure upon which was sometimes 
tolerated, but at other times painful. The following symptoms were noted : 
tongue slightly furred, anorexia, thirst, constipation, scantiness of urine, no 
headache or unusual heat of head during any part of his sickness. He 
vomited at intervals from about the 7th to the 10th of April, when the 
irritability of stomach ceased, and there was no return of this symptom. 

About April 7th, the respiration was first observed to be irregular and 
sighing, and the pulse intermittent. These symptoms, so tardily developed, 
were the first which indicated cerebral disease. He now lay most of the 
time in bed, with eyes closed, surface commonly pale, with occasional rose- 
colored spots or patches upon the cheek or forehead. The pupils responded 
to light in the usual manner till near the close of life, but bright lights 
were painful ; the last two or three days of his life the left pupil was more 
dilated than the right. He had no convulsions or any spasmodic move- 
ment, and was conscious till within a few hours of death ; the mother 



374 MENINGITIS, SIMPLE AND TUBERCULAR. 

states that there was unequivocal evidence of his recognition of her on the 
last day of his life. He died April 17th, nearly three weeks after the 
commencement of the disease, and ten days after the commencement of 
symptoms which were distinctly referable to the brain. 

Autop"!/. — Abdominal organs healthy, though epigastric pain had been 
so constant and prominent a symptom ; brain and its membranes some- 
what injected. The meninges covering the base of the brain from the 
most prominent part of the pons Varolii to the first pair of nerves pre- 
sented evidences of inflammation. There was such opacity of the pia 
mater in places, as to conceal the brain from view. The anterior and 
middle lobes of each hemisphere were glued together by fibrinous exuda- 
tion, and on the left side, along the fissure of Sylvius, was a thick deposit 
of the same character. The lateral ventricles contained about an ounce 
of clear serum, and about half an ounce escaped from the base of the brain. 
The foramen of Monro was considerably enlarged, and the brain-substance 
surrounding the lateral ventricles was somewhat softened, but not in a 
notable degree. 

In this case it is seen that the prominent symptom, and, indeed, almost 
the only marked symptom in the first stages of the disease, was pain in the 
abdomen, and yet the abdominal organs were healthy. At the very 
moment when it was highly important that a correct diagnosis should be 
made, the evidences of cerebral disease were lacking. This case is, there- 
fore, interesting on account of the variation in symptoms from those in the 
usual form of meningitis. There were no convulsions, and consciousness 
was retained as well as vision till near the close of life, and yet the lesions 
were such as are commonly present in meningeal inflammation. It is such 
cases that a wrong diagnosis is apt to be made, to the injury of the patient 
and the reputation of the physician. 

Occasionally meningitis may continue so long as to almost justify its 
being called chronic, even when there is a large amount of exudation upon 
the pia mater. In the few cases which end favorably, the symptoms abate 
gradually. I shall describe more fully the termination in speaking of 
prognosis. 

Diagnosis. — It is of the utmost importance to diagnosticate meningitis 
in its first stages, since treatment, to be successful, must be commenced early. 
Certain writers describe at length the means of diagnosticating the simple 
from the tubercular form of the inflammation. Diflerential diagnosis is 
often difiicult, and sometimes impossible ; but it matters little, practically, 
whether the form of the disease is ascertained. On the other hand, it is 
very important, in order that the treatment be appropriate, to diagnosticate 
the premonitory or initial stage of meningitis from certain other affections 
not located within the cranium. Sometimes remittent or continued fever, 
or constitutional disturbances arising from irritation in the digestive system, 
simulate closely incipient meningeal disease, so that the greatest care and 
discrimination are required in order to make a correct diagnosis. Within 
a comparatively recent period I have known, in three different instances, 



PROGNOSIS. 375 

experienced physicians of this city mistake commencing meningitis for 
fevers, not aware of the serious error they had made till the inflammation 
had reached a stage from which recovery was impossible. In order to 
avoid error in the diagnosis in the premonitory or initial stage of menin- 
gitis, the physician should take time to observe the physiognomy, and note 
every symptom. More than one protracted visit is often required to re- 
move doubt as to the exact pathological state. 

Meningitis is usually preceded and in its commencement accompanied 
by greater restlessness, fretfulness, intolerance of light, and greater varia- 
tion of symptoms than most other maladies. One familiar with the physi- 
ognomy of infancy and childhood, will discover in the features indication 
of greater suffering, of more serious sickness, than is commonly present in 
other maladies, which simulate this. 

Sometimes the sudden disappearance of a chronic eruption upon the 
scalp will aid in the diagnosis. This is a sign of importance, taken in 
connection with the symptoms. Headache and vomiting, symptoms of 
early occurrence, should especially arrest attention, or, in absence of head- 
ache, pain of a neuralgic character in some other part. But we may re- 
peat that familiarity with the symptoms of meningitis will not protect from 
error if the visits of the physician are hasty, and his examinations im- 
perfect. When the eyes become affected, the respiration and circulation 
irregular, and especially when convulsive attacks begin, diagnosis is easy. 
In fact, an incorrect diagnosis would then be unpardonable; but, unfor- 
tunately, if proper treatment has not been commenced till this period, it 
will be of little service. 

Prognosis. — Meningitis is one of the most fatal maladies of early life. 
Whether the form is simple or tubercular, if the initial stage has passed 
without proper treatment, death may be considered inevitable. Tubercular 
meningitis, however early recognized, is rarely amenable to treatment. M. 
Guersant {Die, Med., t. xix, p. 403) believes that recovery fi'ora the first 
stage of this form of meningitis is possible, "In the second stage," says 
he, " I have not seen one child recover out of a hundred, and even those 
who seemed to have recovered have either sunk afterwards under a return 
of the same disease in its acute form, or have died of phthisis. As to 
patients in whom the disease has reached its third stage, I have never seen 
them improve even for a moment." The very few reported cases which 
resulted favorably may have been, as M. Guersant has intimated in the 
context, cases of the simple form. Rilliet and Barthez believe that in a 
few instances tubercular meningitis has been cured in its first stages, but 
they state also that the disease is apt to return. 

The prognosis in simple meningitis is not so unfavorable, provided treat- 
ment is commenced at a sufficiently early period. It is now generally 
admitted that the simple form may not infrequently be averted, when 
threatening, and even arrested in its incipiency. In many such cases Ave 



376 MENINGITIS, SIMPLE AND TUBERCULAR. 

cannot, from the nature of the disease, be certain that the diagnosis is 
correct. But when we see children relieved, who present precisely those 
premonitor)^ and even initial symptoms which occur in meningitis, we 
must believe that at least some of them would have had the genuine dis- 
ease if not relieved by the measures employed. That recovery is possible 
from simple meningitis in its commencement, is also obvious from the fact 
that a few recover even in the second stage, when there can be no error of 
diagnosis. 

I have known but two recoveries from meningitis when it had continued 
so long and had reached that degree that the function of the brain and 
cranial nerves was impaired. One of these recovered with the permanent 
loss of sight, the other with the loss of hearing. Both seem to have ordi- 
nary intelligence. Another case has been communicated to me, in which 
the patient, a little girl, recovered completely, but for several months after 
the attack seemed nearly idiotic. 

Sometimes even in the second stage of meningitis treatment properly 
employed is attended by amelioration of symptoms. Though such im- 
provement may serve to encourage physician and friends, it should not be 
the basis of a favorable prognosis unless it continue three or four days. 

Apparent improvement during a few hours or a considerable part of a 
day is not unusual in those who finally die. Thus, in an infant whose 
bowels were previously confined, I have known the pulse and respiration 
to become more regular and the symptoms generally improve, though only 
for a brief period, by the action of a purgative. Dr. Watson says of the 
advanced stages of this disease, it is " often attended with remissions, some- 
times sudden, and sometimes gradual, deceitful appearances of convales- 
cence. The child regains the use of its senses, recognizes those about him 
again, appears to his anxious parents to be recovering, but in a day or two 
it relapses into a state of deeper coma than before. And these fallacious 
symptoms of improvement may occur more than once." 

Most fatal cases of meningitis terminate between the third or fourth and 
the twentieth day, the duration varying according to the extent and inten- 
sity of the inflammation, and the vigor and age of the patient. But there 
are cases in which it may continue much longer. It is surprising some- 
times how long the patient lives, when the symptoms are such that death 
seems impending. Sensation and consciousness may be extinguished, con- 
vulsions occur at intervals, and the surface have acquired almost a cadav- 
eric aspect, and yet the patient lives on. Rilliet and Barthez say, "Often 
have we inscribed upon our notes death imminent, and been astonished the 
next day to find still alive children to whom we had scarcely allowed two 
hours of life." The symptom which I have found to be the most reliable 
prognostic of the near approach of death, has been a pulse gradually be- 
coming more frequent and feeble, though other symptoms remain as before. 



TREATMENT. 377 

This change in the pulse is usually very apparent during the last twenty- 
four hours of life. 

Treatment. — Such remedial measures should be prescribed during the 
premonitory stage as are calculated to relieve the fretfulness or irritability 
of temper and quiet the action of the brain, and, at the same time, pro- 
duce a derivative effect from this organ. To this end the patient should 
be kept from all causes of excitement, and the bowels should be opened 
daily, if not naturally, by the use of proper medicines. A mustard foot- 
bath at night and occasionally through the day is useful, as it produces 
both a derivative and soothing effect. It will commonly produce a few 
hours' undisturbed rest, while all other measures except medicine fail. 
If dentition is taking place and the gums are swollen, it is sometimes 
proper to scarify them. This operation, by diminishing the swelling and 
tenderness, may diminish the irritability of system. In most cases in 
which there are symptoms threatening meningitis, moderate counter-irri- 
tation behind the ears is required. The fact that the disease sometimes 
follows the recession of cutaneous eruptions of the scalp shows the impor- 
tance of this remedy; but it is not advisable to produce counter-irritation 
over a large surface, since this may increase the restlessness of the child, 
and aggravate rather than relieve the state of the head. West says : 
" Another inquiry that you may put is, when are you to employ blisters ? 
Certainly not at the beginning of the disease, when they would increase 
the genei'al irritation and do more harm than good. At a later period 
they may be of service, when the excitement is about to yield to that 
stupor which usually precedes the state of complete coma. They should 
then be applied to the nape of the neck or to the vertex." Vesication em- 
ployed at so late a period of the malady can produce in my opinion little 
effect in arresting meningitis ; besides, counter-irritation at the vertex or 
back of the neck is too far removed from the seat of the disease. I have 
never known it, when employed in the manner which I shall advise, to 
increase the restlessness. I have many times prescribed vesication — 
sometimes when the symptoms passed off and there was restoration to 
health ; at other times, when meningitis supervened with its usual result 
— and I have never regretted the prescription. Cautharidal collodion 
applied with a brush answers the purpose, and from the convenience of 
its application is to be preferred. It does hot vesicate deeply, or produce 
a troublesome sore. If symptoms indicating the approach of meningitis 
continue, bromide of potassium should be given in decided doses. We will 
speak more of this in our remarks on the treatment of the disease. 

Many children who are threatened with meningitis are scrofulous. 
They have already shown symptoms of tubercular disease. They are, 
perhaps, to a certain extent, emaciated, and may have been affected with 
a cough. The premonitory symptoms in these children indicate the ap- 
proach of the tubercular form of meningitis, and a more sustaining course 



378 MENINGITIS, SIMPLE AND TUBERCULAR. 

of treatment is required than in those who are robust. To such children 
cod-liver oil may be profitably given, three times daily, together with the 
syrup of the iodide of iron, and perhaps the bromide. They should also 
be taken into the open air, with proper precautions, and every hygienic 
measure should be employed which will be likely to invigorate the system 
without exciting the brain. 

Loss of blood is not, in general, required during the prodromic period 
nor in the disease. Those of a strumous cachexia, or those, whether 
strumous or not, who are under the age of two years, do not, unless in 
very rare instances, require depletion by leeches, much less by venesec- 
tion. There is one class of patients in whom the early loss of blood may, 
doubtless, be of service, namely, those who in a state of robust health are 
suddenly seized with the inflammation. Leeches should then be applied 
to the head of the patient, if he is seen at an early period. 

The propriety of using opium to allay irritability of system in those 
threatened with meningitis is viewed differently by physicians. Bouchut 
says: "Opiates have the inconvenience of increasing constipation, but 
they are very useful in calming the state of cerebral excitement of young 
infants. Laudanum should be given in a draught in a narcotic dose, at 
short intervals, gradually increasing the dose of it until sleep is obtained." 
I prefer, in order to relieve the restlessness, the use of the bromide of po- 
tassium. From two to three, or five, grains may be given, and, if neces- 
sary, repeated after two or three houi-s. 

Often, notwithstanding the measures employed, the patient grows worse, 
the symptoms become more continuous, others more alarming arise, and 
meningitis declares itself. For internal treatment there are two medicines 
which are extensively used by the profession — in fact, to the exclusion of 
nearly all others — the one calomel, the other bromide of potassium. Those 
who employ the bromide as the main remedy commonly also prescribe 
single occasional doses of calomel as an eligible purgative when there is 
constipation, so that half a dozen or more doses may be given in the course 
of the disease. By those who depend upon calomel as the main remedy, 
it is given not only to keep up a relaxed state of the bowels, but also in 
the belief that it arrests the exudation from the meninges. These last 
give it daily in small doses. 

My observations have not been favorable to the use of calomel, except 
as an occasional purgative. When administered daily, it has a very de- 
pressing effect, and it is to be recollected that this is a malady in which the 
vital powers rapidly sink in consequence of the loss of appetite and the 
frequent vomiting. In tubercular meningitis, it is obvious that any remedy 
which greatly reduces the strength may promote the formation of tubercles, 
and thereby diminish the chances of recovery. Cases have occurred in 
which calomel was given at short intervals for several successive days, and 
though the meningitis seemed to be relieved, death resulted from sheer ex- 



TREATMENT. 379 

haustion, or from some intercurrent affection, the result of exhaustion, or of 
the remedy. In one case related to me, fatal gangrene of the mouth, the 
result of the mercurial treatment, supervened after the meningitis had ap- 
parently subsided. Unless, therefore, statistics show that a larger propor- 
tion recover by the use of calomel than by bromide of potassium, we should 
prefer the safer agent. Now, while certain patients recover who exhibit 
symptoms which are premonitory of meningitis, and a few from meningitis 
itself, by the use of bromide of potassium, restoration to health by the calo- 
mel treatment is certainly very rare, if there are unequivocal evidences of 
meningeal inflammation. Dr. Whytt, who lived in the time when calomel 
and loss of blood were commonly prescribed not only in this but in other 
diseases, never saw a favorable case. Moreover, physicians of the present 
time incline more and more to the use of the bromide, which is now su- 
perseding both calomel and iodide of potassium as the main remedy for 
meningitis. 

The bromide of potassium should be given early in the premonitory 
period. If, by a careful examination, the absence of any other local dis- 
ease or of a constitutional affection which might give rise to similar symp- 
toms is ascertained, this agent should immediately be prescribed. The 
symptoms at this early period are often so obscure that a positive diag- 
nosis cannot be made ; but it is better to give the bromide even if the 
diagnosis is wrong, and no meningeal disease is threatening, than to err 
on the other side and withhold its use in the prodromic and initial period 
of the true disease. An infant from six to twelve months old should take 
two grains every two hours, and older children a proportionate dose. 
Larger doses may in some cases be administered. When thus given, the 
bromide soon produces a calmative effect on the nervous system, and the 
quantity of urine, previously scanty, is in most patients largely increased. 
If with the regular and continued use of bromide of potassium there is no 
improvement, the case is without remedy. 

Throughout the disease, as well as in its commencement, the bromide of 
potassium should, therefore, be employed until it is obvious that there is 
no chance whatever of improvement, when medication may propei'ly be 
discontinued. The best remedy for the convulsions which are apt to occur 
sooner or later is still the bromide or hydrate of chloral. The apart- 
ment should be dark and quiet; a moderate degree of vesication should be 
produced behind the ears, and the head be kept cool. In simple menin- 
gitis occurring in children three or four years of age or older, previously 
healthy and robust, it is proper to place a bladder with pounded ice over 
the head, separated perhaps by two or three thicknesses of muslin, pro- 
vided that the temperature is elevated, as it ordinarily is. If there is not 
much heat, or if the child is considerably prostrated, a cloth wrung out of 
cool water will be sufficient. Bouchut recommends irrigation, and con- 
demns the mode of applying cold which is recommended above. Says he, 



380 SPURIOUS HYDROCEPHALUS. 

"Refrigerants external to the cranium are often employed, and their use 
appears very rational ; still they do not possess a very great efficacy. The 
application of compresses moistened with cold water, ice in a bladder and 
laid on the forehead, are bad remedies, which, by causing too considerable 
alternations of heat and cold, are rather noxious than useful to the child. 
If it is wished to employ refrigerants, recourse should be had to continual 
irrigation. The patient is not to be disturbed in its bed; the head should 
be placed on a cushion, the hair being cut very short; the neck is bound 
moderately tight by an impermeable stuff, so placed on each side as to 
form a gutter, so that the water which has been used in the irrigation can 
run off from each side of the bed without wetting the body of the child. 
Having arranged these, a jar filled with water of a moderate temperature, 
64° Fahr., is placed above the patient ; a siphon with a tap is to be placed 
in the jar, to moderate at will the flow of the liquid. To this tap is fastened 
a skein of loose thread for the purpose of conducting the water to the fore- 
head, so as to avoid the continuous dropping of the liquid, which would be 
insupportable." If, however, there is an attentive nurse, who renews the 
wet cloth sufficiently often, there does not seem to be any danger from re- 
action, as feared by Bouchut. Irrigation requires as constant attention, 
in consequence of the restlessness of the child, as does the treatment by a 
wet cloth, in order that there be no interruption in the employment of it. 
Few children Avill remain quiet with a descent of water upon the head, 
except those who have become entirely insensible, and in such neither a 
wet cloth nor irrigation affords any material benefit. In simple meningitis 
in its first stages, the diet should be mild and in moderate quantity ; in the 
tubercular form it should be more nourishing ; beef tea and milk-porridge 
are required. In both the simple and tubercular form, at an advanced 
stage, the most nourishing food is required, but stimulants should not be 
given unless near the close of life, when the vital powers are failing. 



CHAPTEE X. 

SPURIOUS HYDROCEPHALUS. 

The disease known as spurious hydrocephalus might with more propriety 
be called spurious meningitis. It received its appellation at the time when 
meningitis of early life was believed to be essentially a hydrocephalus, and 
was so called. Attention was first directed to this malady by London 
physicians of the last generation, particularly Drs. Gooch, Abercrombie, 
and Marshall Hall, and little can be added to their description of its symp- 
toms. 



ANATOMICAL CHARACTERS. 381 

Anatomical Characters. — This disease, though resembling menin- 
gitis in certain of its phenomena, is not in its nature inflammatory, nor is 
it primary. It is the result of some malady often chronic, but occasion- 
ally acute, which has produced exhaustion, especially of the nervous sys- 
tem. When it commences, there is usually more or less emaciation, and 
the symptoms of the primarj^ disease are present. To this disease the lesions 
pertain which are found in other organs besides the brain. 

The state of the brain in spurious hydrocephalus is not the same in all 
cases. In some thei*e is no appeciable anatomical alteration in this organ. 
There is no apparent diflerence, either in the meninges or the brain itself, 
from the condition which we often observe in those who have died of dis- 
eases which do not affect the cerebro-spinal system. In such cases the path- 
ological state is simply deficient innervation, or if there is a structural 
change in the minute anatomy of the brain, pathologists have not yet dis- 
covered it. 

The following case, which occurred in the Child's Hospital of this city, 
is an example of this form of spurious hydrocephalus : 

Case. — ^A female infant, six months old, died on the 24th day of April, 
1862, with the following histoiy : It was wet-nursed, fleshy, and apparently 
well, till six days before death, when symptoms of gastro-iutestinal inflam- 
mation were suddenly developed. The vomiting, especially, was severe, 
continuing forty-eight hours. When it ceased, drowsiness supervened, and 
continued till the close of life. The face during the four days of stupor 
was pallid and cool ; eyes partly open, pupils sluggish, but of equal size; 
bowels rather torpid ; anterior fontanelle depressed. When aroused, the 
infant noticed objects for a moment, and immediately relapsed into sleep; 
pulse accelerated and not intermittent, the day before death numbering 
one hundred and fifty ; respiration accelerated, without sighing, number- 
ing on the same day thirty. There were no convulsions, and death occurred 
quietly. The brain weighed twenty and a half ounces, and its appearance 
was perfectly healthy, both as regards consistence and vascularity. The 
amount of cerebro-spinal fluid in the ventricles and at the base of the brain 
was not notably increased. The stomach, small and large intestines, were 
vascular in streaks and patches. 

In this case the cerebral symptoms were obviously due to exhaustion oc- 
curring at an early period, in consequence of the severity of the gastro- 
intestinal affection. 

In a majority of cases, however, of spurious hydrocephalus, according to 
ray observation, there is an anatomical alteration in the state of the brain 
and meninges. This consists in passive congestion of the veins, often with 
transudation of serum. At the same time the cranial sinuses are congested, 
and are found at the post-mortem examination to contain larger and more 
numerous clots than are present in those who die of diseases which do not 
afl!ect the encephalon. Cases might be cited as examples. The cause of 
this congestion and efflision is, in great mefisure, feebleness of the circula- 
tion due to the general exhaustion of the patient. But there is another 



382 SPURIOUS HYDROCEPHALUS. 

cause. lu protracted diseases, especially those of a diarrhoeal character, 
there is more or less wasting of the brain as well as of other parts. This 
naturalh', by way of compensation, gives rise to congestion of the cerebral 
veins and to transudation of serum. 

The transudation commonly occurs in this malady over the superior sur- 
face of the brain and in the subarachnoidal space, perhaps also more or 
less in the lateral ventricles. So common is it in the last stage of infantile 
entero-colitis, the summer epidemic of the cities, that this stage, which is 
really spurious hydrocephalus, has been called the stage of effusion. I shall 
relate in another place examples which show the anatomical characters of 
this intestinal disease. 

Symptoms. — Spurious hydrocephalus most frequently results from pro- 
tracted diarrhoeal complaints. It may, however, result from any disease 
which is attended by great prostration. As it ordinarily occurs, the patient 
has for days or weeks been gradually losing flesh and strength. Finally 
drowsiness supervenes, or before the drowsiness there is sometimes a period 
of irritability. 

Marshall Hall describes two stages of spurious hydrocephalus. In the 
first, he says, "The infant becomes irritable, restless, and feverish ; the face 
flushed, the surface hot, and the pulse frequent; there is an undue sensi- 
tiveness of the nerves of feeling, and the little patient starts on being 
touched, or from any sudden noise ; there are sighing and moaning during 
sleep, and screaming ; the bowels ai'e flatulent and loose, and the evacua- 
tions are mucous and disordered." The second stage he describes as that 
of torpor. The first stage often, however, does not present those promi- 
nent symptoms which have been described by Dr. Hall, and this stage may 
even be absent, or not appreciable, especially in young infants. 

Whether or not commencing with the stage of irritability, the disease, 
if not checked, gradually increases. The child soon becomes drowsy. He 
may be aroused for a moment, but, unless constantly disturbed, immedi- 
ately relapses into sleep. He is sometimes fretful when aroused, but in 
other instances is quite indifferent, observing without apparent interest 
objects employed for the purpose of amusing him. Often there are indi- 
cations of cerebral pain or distress, as contraction of the eyebrows, etc., 
but many of those affected are too young to make known their sensations. 
Convulsions sometimes occur towards the close of life, but they are not so 
common in this disease as in meningitis. When they do occur, they are 
generally partial and often slight. The pulse is accelerated in most patients 
prior to and in the commencement of spurious hydrocephalus. As the 
disease advances it becomes irregular and intermittent, and towards the 
close of life it is progressively more frequent and feeble. The respiration 
at first is not much disturbed, but at length it becomes irregular, like the 
pulse. It is feeble and accompanied by sighs. Occasionally there is slight 
cough. The eyelids are partly open, the pupils no longer respond to light. 



SYMPTOMS. 383 

and in advanced cases they have a bleared appearance. The diarrhoea, 
Avhich in most instances precedes and causes this malady, continues till the 
stage of stupor arrives, when the evacuations become less frequent or cease 
altogether. In infants the stools are frequently green, in older children 
brown and sometimes slimy. The febrile heat of surface, which preceded 
the disease and was present in its commencement, disappears; the face and 
hands become cool, the features pallid, and the anterior fontanelle, if open, 
is depressed. Death finally occurs in a state of coma, or, if the disease is 
recognized and proper remedial measures employed, the result may be 
favorable, even when the sjanptoms are such that if meningeal inflamma- 
tion were the disease we would consider the case necessarily fatal. 

The following case is an example of spurious meningitis as we often 
meet it in practice : 

Case. — On the 13th day of March, 1859, 1 was asked to see a male child 
twenty-two months old, the records of whose case are as follows : 

"Was well till about thi-ee weeks ago, since which time he has had diar- 
rhoea, with febrile symptoms ; pulse 162, respiration 52 ; has a slight cough, 
with a few mucous rales ; resonance on percussion of chest good ; is some- 
what emaciated, and appears languid; tongue moist and slightly furred. 
Plas all the incisor and three anterior molar teeth, and the gum is swollen 
over the remaining anterior molar and two canine teeth." 

From the 14th to the 18th there was no material alteration in his symp- 
toms, with the exception that the diarrhoea was partially restrained by 
Dover's powder in one and a half grain doses. On these five days the 
stools numbered daily from one to six. The pulse was uniformly frequent, 
varying from 124 to 156, and the respiration on two days, when its fre- 
quency was ascertained, numbered 56 and 46. 

"March 19th, pulse 124; has become drowsy since yesterday, and when 
aroused is fretful. Omit Dover's powder. Treatment, cold applications 
to the head, mustard pediluvia. 

"Evening, pulse 136; eyes constantly closed and head reclining; sur- 
face generally warm ; tongue dry and furred ; vomited at first, but has not 
in three or four days. Apply cautharidal collodion behind each ear, and 
continue the local treatment. 

"20th, pulse 130, is constantly sleeping, and when aroused is very fretful 
and soon relapses into sleep ; no unnatural heat of head, and no dejection 
since yesterday. Treatment, a dose of castor oil, nourishing diet. 

"21st, drowsiness as before; cheeks sometimes flushed, sometimes pale; 
pupils sensitive to light ; margins of eyelids covered with secretion. The 
bowels have been opened by the oil." 

On the 22d and 23d there was no material change in the symptoms. He 
was constantly sleeping, except for a moment when shaken. More active 
stimulation was now employed. Brandy was prescribed, to be given every 
two hours; beef tea and milk porridge frequently. 

On the following day, the 24th, he was more fretful, and less drowsy. 
Brandy and beef tea were continued. 

On the 25th, with the same treatment, there was still further improve- 
ment; drowsiness nearly gone and less fretful n ess than yesterday; rolls 
the head occasionally and docs not appear to see distinctly; has a slight 
cough; bowels nearly regular; pulse 100; respiration natural; surface 



384 SPURIOUS HYDROCEPHALUS. 

warm, and no nnnatural heat of head. The same treatment was continued, 
and he rapidly and t'Lilly recovered. 

This case is interesting on account of the long duration of marked drow- 
siness, which continued five days, and yet the patient recovered entirely 
in the space of two or three days under the use of brandy and beef tea. 

In May, 1860, I was called to treat a very similar ease. A child, 
twenty months old, had diarrhoea for two weeks, the stools being of a 
dark-brown color, thin and offensive. He was at first very irritable. The 
pulse was constantly above 130, and the respiration was correspondingly 
increased. The stage of drowsiness finally supervened, and for two days 
he was constantly asleep unless aroused by being shaken. During the 
somnolent stage the jiulse numbered 140, respiration 36. The face and 
extremities were cool and he finally had a slight convulsion. By stimu- 
lants and nutritious diet he began immediately to improve, and was soon 
out of danger. 

In the following case the result was unfavorable. This case is interest- 
ing on account of the anatomical characters of the disease as disclosed by 
the post-mortem examination. It is an example of that large class of 
cases in which spurious hydrocephalus is associated with congestion of the 
cerebral vessels and serous eff"usion. It is exceptional, however, as regards 
the long duration of drowsiness. Ordinarily, protracted diarrhoeal maladies 
which end in congestion and effusion, terminate fatally in three or four 
days after the drowsy period arrives. 

Case. — "Dec. 13th, 1861, called to-day to a German infant eighteen 
months old. It has had diarrhoea four weeks without regular and proper 
medical attendance ; stools from the first brown and thin ; during the last 
eight or nine days has been drowsy; when aroused, opens his eyes and is 
very fretful, but immediately the upper eyelids gradually droop, and, unless 
disturbed, he remains asleep with his eyes partially open ; forehead warm, 
face cool and pallid, and limbs also rather cool ; pulse 164, respiration 32 ; 
has had a slight cough about one week, and slight dulness on percussion 
over the left infra-scapular region ; depression of infra-mammary region 
on inspiration. Treatment: Ammon. carbonat. gr. 1 every two hours; 
nourishing diet. 

"Dec. 20th, has continued drowsy since the last record; pupils mode- 
rately dilated ; a thick secretion between eyelids; right pupil considerably 
larger than the left; vision apparently lost during the three last days ; 
pulse over 140; respiration 44 per minute, accompanied by sighing since 
the 18th ; moans much when awake ; rolls the head frequently ; during the 
last six days the surfiice back of the ears has been constantly sore by 
vesication ; takes the most nutritious diet, with brandy. The dejections 
remain thin and brown, and number three or four daily. 

" From this date the diarrhtea continued, except as it was restrained by 
vegetable astringents. The pulse continued frequent, and a slight cough 
remained. There was on the 21st and 22d partial abatement of the 
drowsiness, but on the 23d it was grfeater than ever. The body was some- 



DIAGNOSIS — PROGNOSIS — TREATMENT. 385 

what reduced at the commencement of the cerebral sj^mptoms, but it was 
now considerably emaciated. The prostration increased daily, and the 
hands were observed to tremble. The face and hands became more cold, 
while the head was warm. On the 24th partial convulsions occurred, fol- 
lowed by coma and death. 

" The cerebral veins and sinuses were generally congested, except in the 
anterior portion of the brain, where the appearance was normal. Between 
the brain and its membranous covering, chiefly at the vertex and the base, 
was an effusion of clear serum. The whole amount of this fluid was esti- 
mated at two ounces. On slicing the brain, numerous ' puncta vasculosa ' 
were seen, both in the gray and white portions. With the exception of the 
congestion, the substance of the brain presented its normal appearance. 
No inflammatory lesions were present. We were not permitted to ex- 
amine the condition of the intestines." 

Diagnosis. — The only disease with which spurious hydrocephalus is 
liable to be confounded is meningitis. The points of differential diagnosis 
are the history of the case, especially the antecedent diarrhoea or other 
exhausting ailment, evidence of prostration when the cerebral malady 
commenced, depression of the anterior fontanelle in young children, and 
the cool face and extremities. 

Prognosis. — If the pathological state of the brain is simple exhaustion, 
the disease can often be arrested by judicious treatment. If an incorrect 
diagnosis be made, and the treatment employed is that appropriate for 
meningitis, which it so closely simulates, death is almost inevitable. If 
transudation of serum has occurred, unless slight, the result is apt to be 
unfavorable, whatever may be the treatment. This disease in childhood 
is more easily managed than in infancy, but is less frequent. The prog- 
nosis is better in the cool mouths than during the heat of summer. It is 
more favorable if the child is over than if under the age of one year. The 
occurrence of an irregular and intermittent pulse, of respiration accom- 
panied by sighs, of inequality in the pupils or their sluggish movements, 
with increasing stupor, indicates an unfavorable issue. The cui-e of the 
primary disease, with the pulse and inspiration still natural, or accelerated, 
without change of rhythm, pupils sensitive to light, drowsiness from which 
the patient is easily aroused to a state of entire consciousness, render re- 
covery probable, with proper medication and alimentation. 

Treatment. — The indications of treatment are twofold : first, to remove 
the primary pathological state which is the cause of the spurious hydroceph- 
alus ; and, secondly, to cure the latter. The first is important, since the 
successful treatment of a disease requires the removal of the cause. The 
measures employed for this purpose are pointed out in our description of 
the diarrhoeal and other maladies which produce spurious hydrocephalus. 

We may here say that as spurious hydrocephalus is due in a very large 
proportion of cases to the exhausting effect of long-continued diarrhoea, 



386 ECLAMPSIA. 

astringents and alkalies are required in a majority of eases in the stage of 
irritability, and sometimes also opiates. 

Active sustaining measures are indicated. Exhausted nervous power, 
as well as passive cerebral congestion, requires this. The diet should be 
highly nutritious, comprising such substances as milk and animal broths, 
and should be given frequently. Brandy is required at short intervals. 
Dr. Gooch was in the habit of giving the aromatic spirits of ammonia, 
properly diluted, as a quick and active stimulant. Six or eight drops may 
be given in sweetened water to a child one year old, and repeated every 
hour in cases of urgency. If, by proper treatment of the cause, and by 
the use of stimulants and nutritious food, the patient does not within a 
few hours become less stupid and more conscious, there is that degree of 
nervous exhaustion or of serous transudation from the engorged cerebral 
veins which will render death probable. In some cases it is proper to 
produce moderate vesication behind the ears. 



CHAPTER XL 

ECLAMPSIA. 

The term eclampsia is used in a more restricted sense by some writers 
than by others. It is used in the following pages to designate those con- 
vulsive seizures, clonic in their character, sometimes general, sometimes 
partial, which affect the external muscles. Eclampsia is therefore synony- 
mous with clonic convulsions. It consists in a rapid, forcible, and invol- 
untary muscular contraction, alternating Avith relaxation. It is distin- 
guished from chorea in the fact that the latter is a more permanent state, 
and is characterized by muscular movements which are partially under 
the control of the will, and are not so violent. 

Eclampsia occurs in a great variety of diseases, some of which are located 
in the cerebro-spinal system, some in other parts of the body, and some are 
constitutional. It may also be produced by temporary derangements of 
system, not sufficiently severe to be considered diseases, and by powerful 
mental impressions, those of an emotional nature, affecting the delicate and 
sensitive nervous system of the child. Pathologists recognize three dis- 
tinct forms of eclampsia. The term essential or idiopathic is used when the 
convulsions have no appreciable anatomical character, that is, when there 
is no apparent pathological state in the brain or elsewhere, which gives rise 
to the attack. For example, if a child dies in convulsions from fright,and 
all the organs, including the brain, are found in their normal state, the 



CAUSES. 387 

eclampsia is called idiopathic or essential. If the cause is disease of the 
brain or spinal cord, it is termed symptomatic. If it arises from disease 
elsewhere, as from pneumonia, the term sympathetic is employed. This is 
in the main a good division, but eclampsia may be at the same time sym- 
pathetic and symptomatic, as when it occurs in consequence of congestion 
of brain, which is induced by severe and frequent paroxysms of hooping- 
cough. 

Causes. — Eclampsia occurs at any period, of infancy and childhood, 
but it is much more rare after the period of six or seven years than pre- 
viously. Some children are more liable' to it than others. It is produced 
in one by an agency which in another has no appreciable effect. There 
are some, generally those of an impressible nervous system, who are seized 
with convulsions whenever there is any slight derangement in the digestive 
or other organs. Eclampsia is frequent in certain families. Thus, Bouchut 
mentions a family of ten persons, all of whom had convulsions in their 
infancy. One of them married, and had ten children, all which, with one 
exception, had convulsions. 

The exciting causes of eclampsia are too numerous to be mentioned in 
full. It is a symptom in nearly all cerebral diseases. It is produced in 
the nursling by changes in the milk with which it is nourished. These 
changes are usually due to violent emotions of the mother, as anger, fright, 
and grief, to the use of acescent or indigestible food, or to derangement, 
temporary or permanent, in her health. Thus, in a case related to me, the 
catamenia so affected the milk that the infant was seized with eclampsia at 
each monthly period. In childhood the most common cause of clonic con- 
vulsions is the presence of some irritant in the primse vise. All kinds of 
fruit, even the mildest, may produce eclampsia, especially when eaten un- 
ripe or taken in undue quantity. I have known an infant to be seized with 
convulsions from eating strawberries, which parents usually regard as harm- 
less, and one of the most violent and protracted cases of eclampsia which I 
have witnessed, occurred in a child over the age of six years, from swallow- 
ing, in considerable quantity, the parenchymatous portion of an orange. 
Constipation, worms, dysentery, intussusception, and painful dentition are 
also causes which are located in the digestive apparatus. Inflammation in 
some part of the respiratory apparatus is a not infrequent cause. Thus 
eclampsia occurs occasionally in severe coryza, in consequence, according 
to some, of the proximity of the inflamed surface to the brain, and the 
consequent afflux of blood to this organ. It is a common complication 
also of pertussis and pneumonia. It occurs often at the commencement of 
two of the eruptive fevers, namely, small-pox and scarlet fever, and in the 
course of the latter disease. 

Violent emotions of the child may also cause eclampsia. Bouchut 
relates the case of a girl, five years old, who was corrected before her 
companions, and was so affected by anger that convulsions ensued. 



388 ECLAMPSIA. 

Residence in close aud overheated apartments, or in streets ^vhere the air 
is loaded with offensive vapors and is stifling, is a predisposing cause, so 
that there is a larger proportion of deaths from convulsions in the cities 
than in the country. 

In young children, burns, even when not very severe, are apt to termi- 
nate suddenly in eclampsia, succeeded by coma and death. Urinary 
calculi, both renal and vesical, frequently produce the same result. 

Such are the more common causes of eclampsia. It is seen that they 
are of two kinds, predisposing and exciting. An excitable or impressible 
state of the nervous system constitutes the chief predisposition to the 
disease. Plethora, or its opposite state, anaemia, increases the liability to 
an attack. 

Premonitory Stage. — In the majority of cases there are prodromic 
symptoms, which the experienced and careful physician can detect, so as 
to forewarn friends. The child is perhaps more or less drow^sy, and, when 
disturbed, fretful. The eyes often have a wild or unnatural appearance ; 
occasionally they are fixed for a moment on an object, and yet apparently 
without noticing it. The sleep is disturbed ; in some there is unusual 
heat of head, and, if old enough, complaint of headache. At times, es- 
pecially if the primary disease is febrile or inflammatory, there is inco- 
herence of thought or expression, or even actual delirium. In some chil- 
dren, when eclampsia is threatening, the thumbs are seen to be carried 
often across the palms. I have observed this especially during the con- 
vulsive cough of pertussis. A very important prognostic symptom is a 
sudden starting, or twitching of the limbs. This shows that the nervous 
system is profoundly impressed, and but slight additional excitation is 
required to develop eclampsia. This sudden starting not infrequently 
precedes the attack several hours, and gives sufiicient forewarning. 

The prodromic symptoms are often disregarded by friends who do not 
understand their significance. Even physicians, in the haste of their 
visits, in many instances do not notice them. The symptoms which pre- 
cede symptomatic and sympathetic eclampsia are, moreover, blended with 
those of the primary affection, and hence another reason why they are 
apt to be overlooked. When the convulsions are about to commence, the 
child generally lies quiet; the eyes are open and fixed. If spoken to or 
shaken, he takes no notice, and does not speak. The direction of the 
eyes is then changed ; often they are turned up ; sometimes there is stra- 
bismus. The face may be pale or flushed, and often, especially in cerebral 
diseases, the features present patches or streaks of a flushed appearance, 
while around them the natural color is preserved. Immediately before 
the spasmodic movements the patient occasionally utters a piercing scream, 
which is probably involuntary, though it seems like a supplication for help. 
The duration of the prodromic stage is very different in different cases. 
It may last from a few minutes to several hours, or even more than a day. 



SYMPTOMS. 389 

Symptoms. — Eclampsia is general or partial. If general, the muscles 
of the face, eyes, eyelids, and of all the limbs, are in a state of rapid 
involuntary conti'action, altei'nating with relaxation. The features lose 
their natural expression and are distorted ; the mouth is drawn out of 
shape, often to one side, by the violent muscular action ; the teeth are 
pressed together by tonic contraction of the masseters, and may be vio- 
lently struck together, so as to lacerate the tongue, if it protrude, or are 
ground upon each other. Unless the attack is of short duration, frothy 
saliva, perhaps tinged with blood from the injured tongue, collects between 
the lips. The eyelids are usually open, and in severe cases the eyes are 
turned so that the pupils are lost under the upper eyelids, or the muscles 
of the eyes are involved in the spasmodic movements, so that the eyeballs 
are forcibly drawn from side to side. Occasionally strabismus occurs. 
While the features are thus distorted, the head is strongly retracted, or is 
turned to one side; the forearms are alternately pronated and supinated; 
the thumbs and fingers are convulsively flexed, so that the thumbs lie 
across the palms and are covered by the fingers; the great toe is adducted, 
the other toes flexed ; and the toes, as well as legs, participate more or less 
in the spasmodic movements. 

In general convulsions, consciousness is usually lost. The head is hot 
previously to and during the attack — at least in the first part of it — and 
the face flushed. In exceptional cases, especially in sympathetic eclampsia, 
the head is cool and the face pale. The pulse is somewhat accelerated, as 
well as the respiration, and the latter is rendered irregular if the respira- 
tory muscles, especially those of the larynx, are involved, as they generally 
are. The sphincters are relaxed during the convulsive attack, so that in 
many cases the urine and stools are passed involuntarily. 

Partial eclampsia is more common than the general form ; it occurs in 
the muscles of the face, including those of the eye, of the face and of one 
or both upper extremities, or of the face and the extremities on one side. 
The spasmodic movements may be even limited to the muscles of the eyes, 
and they often occur only in these muscles and those of the face. Rarely, 
if ever, does eclampsia affect the legs without aflTeeting also the muscles of 
the arms and face. In partial convulsive attacks, sensation and conscious- 
ness are in some patients not entirely lost, but in others they are not mani- 
fested if present. 

The duration of an attack of eclampsia varies in different cases from a 
few minutes to several hours. The 'average is not more than from five to 
fifteen minutes. It does not often continue longer than three or four hours 
in the severest cases. It is sometimes said to last a much longer time, even 
for days, but there are in these cases intermissions. Violent attacks are 
usually short. 

When the convulsion ends favorably, the spasmodic movements become 
less and less strong, and finally cease. The child then takes a deep in- 



390 ECLAMPSIA. 

spiration, after which it lies quiet, and the respiration remains regular or 
moderately accelerated. Some fully recover in a few minutes if the eclamp- 
sia has been light and the cause transient, and seem to experience no in- 
convenience except soreness of the muscles and fatigue. Others soon re- 
cover consciousness, and their temperature, respiration, and circulation 
become natural, but they remain dull for a time, their minds are bewildered, 
and they are perhaps unable to speak. In a few hours these untoward 
symptoms pass away. In essential, and in a large proportion of cases of 
sympathetic eclampsia, if properly treated, and if the cause is recognized 
and removed, there is no recui'rence of the convulsion ; with others it is 
different. In many cases, especially of symptomatic eclampsia and of 
sympathetic, in which the cause is grave and persistent, the convulsions 
return after a variable period of a few minutes or a few hours. Six or eight 
or more convulsions may occur within twenty-four hours. Rarely they 
occur several times daily for several consecutive days, but severe convul- 
sions, repeated at short intervals for twenty-four or forty-eight hours, 
usually end in fatal congestion of the brain or serous effusion, I once 
attended an infant about six months old, who had from four to twelve con- 
vulsions daily for eleven days, caused probably by a vesical calculus, as 
there was dysuria, and, at times, bloody urine. Some days after the con- 
vulsions were controlled, while we were deferring exploration of the blad- 
der, death occurred suddenly, and the autopsy was not permitted. This 
case will be detailed elsewhere. Bouchut has witnessed a case of hooping- 
cough in which there were daily convulsions for eighteen days. 

In severe eclampsia, the respiration is so embarrassed and circulation 
so retarded that congestion of various organs results. This passive con- 
gestion in the respiratory organs is indicated by moist rales in the larynx 
and bronchial tubes ; occurring in the brain, it is indicated by profound 
stupor. It has already been stated that death may occur from the cere- 
bral congestion, which, continuing, is apt to end in effusion of serum or 
extravasation of blood. In these cases the convulsive movements cease, 
but there is no return of consciousness. The child lies quiet, as if in sleep, 
Avith pupils not readily acted upon by light, and often somewhat dilated ; 
gradually the limbs grow cool and the pulse feeble, and fatal coma super- 
venes. 

Death does not ordinarily occur from one attack. There are several at 
intervals, during which the stupor is gradually becoming more and more 
profound, till, finally, there is total loss of consciousness and sensation. 
This is the most frequent mode of death, namely, from coma. Apnoea 
may occur in the first attack, ending life abruptly and unexpectedly, but 
in other instances it does not result till after several seizures, when, at 
length, one more violent than the others interrupts the respiratory function 
and causes death. 

Occasionally, when life is preserved, there is some permanent ill effect 



ANATOMICAL CHARACTERS. 391 

of eclampsia. Bouchut says : " The origin of certain permanent contrac- 
tions which bring on deviation of the head or of other parts, retraction of 
the limbs, paralysis, etc., must be referred to the convulsions of the muscles. 
I have seen several children in whom torticollis had no other cause. The 
drooping of the upper eyelid, strabismus, irregularity of the mouth, severe 
contractions of the limbs, often depend on this influence. These accidents 
are consequences of essential as well as of symptomatic convulsions." 

Anatomical Characters. — The morbid anatomy pertaining to 
eclampsia is in most cases twofold : first, the pathological states which 
precede and cause the convulsive movements ; secondly, those which result 
from them. We have seen that in sympathetic eclampsia the diseases 
which sustain a causative relation are very numerous ; some are constitu- 
tional, others local, and the latter may have their seat in almost any part 
of the economy, distinct from the cerebro-spinal axis. In some cases of 
sympathetic eclampsia the immediate cause is too active a circulation, a 
state of hypersemia of the cerebral vessels. 

It has already been stated that this hypersemia may be diagnosticated 
in young infants in whom the anterior fontanelle is open. Such infants, 
seized with acute inflammation of the mucous surfaces or of the lungs, 
often present a full and rapid pulse and a convex and forcibly pulsating 
fontanelle before the eclampsia begins. In other cases of sympathetic eclamp- 
sia the primary disease induces passive congestion of the brain, and this in 
turn gives rise to convulsions. Eclampsia occurring. during the paroxysms 
of hooping-cough affords an example. In the contagious diseases, as small- 
pox and scarlet fever, eclampsia is doubtless often produced by the direct 
action of the specific virus on the cerebro-spinal system. Therefore, in a 
considerable proportion of cases of eclampsia due to diseases not located 
in the cerebro-spinal system — in other words, of sympathetic eclampsia — 
the primary disease induces a pathological state of the cerebral vessels or 
of the blood which circulates through them, which state immediately pre- 
cedes and accompanies the convulsions. 

In other cases of sympathetic eclampsia the convulsive movements are 
produced by the primary disease, acting directly on the nervous system, 
through the medium of the nerves, without causing any appreciable altera- 
tion in the state of the cerebro-spinal axis. Thus Barrier relates three 
fatal cases of convulsions occurring in pneumonia, in none of which was 
there anything abnormal in the condition of the brain or its membranes. 

The pathological state preceding symptomatic eclampsia differs in dif- 
ferent cases, since convulsions occur in almost every disease of the brain 
and its membranes. The immediate cause of this form of eclampsia may 
be active or passive cerebral congestion, with or without eff'usion ; it may 
be compression of the brain from various causes ; it may be a deficiency 
as well as excess of the cerebro-spinal fluid. 

In essential eclampsia the cause sometimes produces congestion of the 



392 ECLAMPSIA. 

brain prior to the convulsive seizure. In other cases, as Avhen convulsions 
occur immediately from the effect of anger or fright, there is no appre- 
ciable change in the state of the nervous centres previously to the attack. 

Again, eclampsia, especially when severe and protracted, and when 
occurring in successive attacks, may be the cause of certain lesions. It 
produces congestion of the brain and membranes, and perhaps of the spinal 
cord. Sometimes, if the congestion is great, there is also escape of serum 
from the distended capillaries, and the fibrin in the larger vessels, as the 
sinuses, may coagulate. 

The congestion resulting from eclampsia may give rise to extravasation 
of blood and the formation of a clot. If this accident occur, there is often 
paralysis affecting more or less of one side, permanent or gradually dis- 
appearing. 

It may be difficult to decide whether the cerebral congestion precedes 
the eclampsia or is its result ; but in those cases in which it precedes and 
operates as a cause, it is no doubt increased during the convulsive period. 
The spasmodic muscular action, by rendering respiration irregular and 
imperfect, also leads to congestion of the lungs and sometimes of the 
abdominal organs. 

Diagnosis. — The only disease for which there is danger of mistaking 
eclampsia is epilepsy. M. Ozanam mentions the following means of dis- 
tinguishing the two: "Eclampsia differs from epilepsy in the frequent 
occurrence of pi'odromic symptoms ; the clonic form of the convulsions, the 
rare appearance of froth in the mouth, the absence of a hideous livid 
aspect of the countenance, the spasmodic and sobbing character of the 
respiration, frequency of the pulse, and a state of quiet without snoring 
which succeeds an attack." In the young child, however, the above points 
of distinction are not reliable as a means of differential diagnosis. Some 
patients, who seem to have genuine attacks of eclampsia in infancy and 
childhood, prove to be epileptic in subsequent years. The usual period of 
eclampsia is prior to the age of six years. If convulsions occur after this 
age without apparent exciting cause, or from trifling causes, in those who 
have not before had eclampsia, the disease is probably epilepsy ; if prior to 
the age of six years, and especially of three or four, they are in the vast 
majority of cases the convulsions of eclampsia. 

It is often difficult to ascertain the form of eclampsia, whether essential, 
symptomatic, or sympathetic — in other words, to determine the cause — 
till after the convulsions cease. This is especially true when, as is fre- 
quently the case, the physician is not summoned till the convulsive move- 
ments begin, and it is necessary that he should act promptly, with but 
little knowledge of the child's previous history. If there is an obvious 
antecedent disease, as hooping-cough or meningitis, the cause is apparent ; 
but if the previous health has been good, or but slightly disturbed, it may 
be necessary to make more than one visit or examination in order to ascer- 



PKOGNOSIS TREATMENT. 393 

tain the seat and character of the cause. In the majority of cases of con- 
vulsions occurring suddenly in a state of previous good health, the cause 
is seated in the intestines, but sudden and unexpected attacks may be due 
to the commencement of some inflammatory affection, as pneumonia, or 
of a febrile disease, as small-pox. Unless the eclampsia is speedily fatal, 
the physician, if he examine carefully, will, in most cases, soon be able 
to ascertain the nature of the cause, and diagnosticate the form of the 
disease. 

Prognosis. — Symptomatic eclampsia is always serious. If convulsions 
occur in the course of a cerebral disease, it indicates the approach of death, 
but if at the commencement, some recover. The recurrence of it, whatever 
the cerebral disease, is an almost certain prognostic of death. 

In idiopathic or essential convulsions the prognosis depends on the se- 
verity of the attack, and on the age, strength, and previous condition of 
the child. If there are predisposing or co-operating causes, as a nervous 
or excitable temperament, or dentition, the prognosis is less favorable than 
when such causes are absent. 

In sympathetic eclampsia the prognosis varies greatly, according to the 
nature of the primary disease, and often according to the stage of that 
disease. If convulsions occur at the commencement of an eruptive fever, 
they generally subside without untoward symptoms, and the fever pursues 
a favorable course. Eclampsia, after the appearance of the eruption, is 
premonitory of a fatal result. I have not yet known a patient with 
scarlet fever recover who had convulsions after the rash had covered the 
body, and experienced physicians of this city tell me that their observa- 
tions correspond with mine. Dr. J. F. Meigs, however, relates one favor- 
able case. If the cause of the eclampsia is located in or upon the mucous 
surfaces, a majority recover with judicious treatment. In convulsions 
consequent on pneumonia or a burn, more die than recover. 

The prognosis in eclampsia is more favorable if the parallelism of the 
eyes is retained, the pupils remain sensitive to light, and consciousness 
soon returns. A fatal termination may be predicted, if, after the convul- 
sion, the child remains stupid, without any evidence of returning con- 
sciousness. 

Treatment. — Fortunately, inasmuch as the physician is often required 
to treat eclampsia in ignorance of the cause, the same measures are de- 
manded, to a considerable extent, in all cases, whether the form be essen- 
tial, symptomatic, or sympathetic. As early as possible in the attack the 
feet should be placed in hot water to which mustard is added, or, if it can 
be procured with little delay, a general warm bath may be used in place. 
This has a soothing effect upon the nervous system and promotes muscular 
relaxation, while it also produces derivation of blood from the cerebro- 
spinal axis. It is, therefore, useful, especially in those cases in which 
active or passive congestion precedes the eclampsia ; it is also useful as a 



394 ECLAMPSIA. 

preventive of p<as?ive congestion and consequent oedema of the brain, 
lungs, and other organs, which are the most serious results of eclampsia. 
It should be continued from six to fifteen or twenty minutes, according to 
the severity and duration of the attack; at the same time cold applica- 
tions should be made to the head, until its temperature, which is usually 
increased, is reduced. The application of a cloth, frequently wrung out 
of cold water, is the most convenient and ready mode of employing this 
agent. Cold thus employed acts promptly in contracting the vessels of 
the brain and meninges, and diminishing the cerebral congestion. It 
tends, therefore, to remove one of the chief dangers. 

As a large proportion of convulsive attacks originate in the condition 
of the bowels, either solely or in part, it is advisable, unless there is a 
previous diarrhoeal affection, to prescribe an aperient. 

The common enema of soap and water will usually produce a free and 
speedy evacuation, and will sometimes disclose the cause of the eclampsia 
in the expulsion of seeds or other indigestible substances or scybala. A 
cathartic is also often required, especially if the enema fail to produce 
sufficient evacuations. In those that are robust, and especially in those 
beyond the age of two or three years, calomel is an excellent'purgative, 
is easily given, and is prompt in its action. If the symptoms indicate 
intestinal inflammation, the milder purgatives, as castor oil, are prefer- 
able, as they also are in young or feeble children. If the recent ingesta 
of the patient consisted of fruit or of substances of an indigestible char- 
acter, an emetic is appropriate ; a teaspoonful of the syrup of ipecacu- 
anha, repeated if necessary in fifteen or twenty minutes, may be given to 
a young child, or this syrup with the syrup, scillse compositus to one older 
and more robust. Aside from the ejection of the offending substance 
which it produces, an emetic has some effect in controlling the convulsive 
movements. 

Convulsions sometimes cease, apparently, in consequence of the muscular 
relaxation caused by the emetic. By such measures, aided by the bromide 
of potassium, the attack usually ends in a .short time ; but if it continue, and 
there is much heat of head or other indication of active congestion of the 
brain, we may try compression of the carotids by the fingers, as recom- 
mended by Trousseau. This observer believed that he sometimes succeeded 
in diminishing the afflux of blood to the brain, and thereby in shortening 
eclampsia, by this simple expedient. Brown-Sequard (Remarks before 
the United States Medical Association, 1866) has stated that this result is 
due, not so much to compression of the carotid, as to pressure on the cer- 
vical portion of the sympathetic nerve, which (pressure) causes contraction 
of the cerebral vessels. 

If the convulsions do not cease by the use of the above measures, 
one or two leeches may, in certain cases, be applied to the temples if the 
patients are robust, and there is increased heat of face or head. The ab- 



TREATMENT. 395 

straction of blood directly from the head has the obvious effect of diminish- 
ing cerebral congestion, and has been the means of shortening the attack 
and saving life. Antispasmodics have been used for a long period in cases 
of eclampsia, and they are recommended in our standard works. I have 
never observed any benefit from the use in clonic convulsions of either 
assafffitida or valerian ; though I, in former times, frequently prescribed 
such agents both by the mouth and by enema. Chloroform, whether 
inhaled or swallowed, does control the convulsive movements. In pro- 
tracted or frequently recurring eclampsia, especially when it is due to a 
highly sensitive nervous temperament, and there is probably little or no 
cerebral congestion, this is one of the most reliable agents employed by 
inhalation, and it is not unsafe if cautiously used by the physician him- 
self. It should be employed only in the convulsion, and withheld the 
moment the spasmodic movements cease. In symptomatic eclampsia, or 
in the other forms, if there are indications of cerebral congestion, I would 
not recommend its use. Dr. A. P. Merrill (Amer. Jour, of Med. Sci., Oct. 
1865) gives chloroform by the mouth in the treatment of this disease, and 
in doses which most practitioners would hesitate to prescribe. He has 
given even a teaspoonful at a dose, to a child a few years old, with satis- 
factory result. In most of those cases, however, in which chloroform is 
useful, the hydrate of chloral promises to be a safer and efficient substi- 
tute, and it is more easily administered ; but it is inferior to the bromide 
as a remedy for clonic, while it surpasses it for tonic convulsions. 

The propriety of pi-escribing opium in any form of convulsive attacks 
in children is doubted by many on account of the drowsiness which it pro- 
duces. There can be no doubt, however, of the propriety and the good 
effect of its use in certain cases of essential and of sympathetic eclampsia. 
I refer to those cases in which attacks of eclampsia occur with intervals 
during which there is no stupor, and the patient preserves consciousness. 
Opiates may occasionally be of service in other cases, but in such they are 
especially indicated. Thus, recently, in my practice, an infant six weeks 
old, in whom there was an hereditary predisposition to eclampsia, was taken 
with diarrhoea, and soon after with convulsions. The attack was short, 
but after a brief interval it returned, and during the subsequent twelve 
hours there were about twenty convulsions. There was no unusual heat 
of head or prominence of the anterior fontanelle, or other evidence of 
cerebral congestion. The green and unhealthy appearance of the stools 
showed that the cause was located in the intestines. After trial of various 
remedies, among which were antispasmodics, these convulsive seizures were 
soon relieved by the use of paregoric in doses of five drops, which also had 
a salutary effect on the cause of the eclampsia, and in a few days there 
was complete restoration to health. 

In recent times the attention of the profession has been directed to the 
bromide of potassium as a remedy in convulsive disorders. It is ordinarily 



396 ECLAMPSIA. 

prescribed iu solution. It is rapidly absorbed, so that the effects of the 
dose begin to be experienced within two or three minutes after its admin- 
istration if the stomach is empty. It maybe safely administered in all the 
forms of eclampsia, and at any age, in decided doses. I have employed it 
in the eclampsia of the new-born in one-grain doses, and in one instance 
in my practice, the mother gave at one dose thirty grains to a child of 
eighteen months, with pi'ompt arrest of the convulsions and with no appre- 
ciable ill effect. Few medicines are indeed so generally useful for the 
purposes for which they are prescribed, and ill effects are only observed 
after its long-continued employment. But doses much smaller than are 
commonly prescribed are often sufficient, as in the following case: In 
January, 1866, I visited an infant aged six months, who during the pre- 
ceding seven days had had in the average about eight attacks of gen- 
eral eclampsia daily, each lasting about eight or ten minutes. The child 
was nursing, and had no teeth and no decided swelling of the gums. The 
cause was pit)bably a vesical calculus, as the urine was occasionally 
tinged with blood, and Avas passed with pain. Various remedies were 
made use of till February 1st, without diminution in the severity or 
frequency of the attacks: when bromide of potassium was prescribed in 
half-grain doses every six hours. From February 1st to 3d there were 
two convulsions daily. On the 3d the medicine was given every three 
hours, after which there was no further eclampsia. The bromide was dis- 
continued on the 7th. The infant nursed as usual, and its health seemed 
to be re-established, with the exception of those symptoms w^hich indicated 
the presence of a calculus. Examination of the bladder for stone was de- 
ferred for a few days, when, about two weeks subsequently to the last con- 
vulsion, the infant died suddenly and unexpectedly. Though the result of 
this case was unfavorable, the controlling power of even small doses of 
the bromide over the eclampsia was apparent. 

Those children who are subject to eclampsia from trifling causes, and 
sometimes without apparent cause, w^hile their general health is good, are 
often saved from eclampsia by the daily use of the bromide for a time. The 
efficacy of the bromide in epilepsy is well known, and in all those cases of 
eclampsia which approximate epilepsy, and in which it is feared that the 
child will become epileptic, this agent is preferable to all others. It may 
be given in doses of two grains to a child one year old, every two to six 
hours, and an additional half grain or grain for every subsequent year. 

R. Potass, bromid., ^ss. 
Sacch. alb., ^^ss. 
Aq. anisi, gij. 
Dose, one teaspoonful every two to six hours, to a child of one year. 

The treatment of eclampsia obviously should vary in different cases, ac- 
cording to the cause. If it occur in an eruptive fever, as scarlatina, and 
the eruption has receded, active revulsive measures, as hot mustard-baths, 



I 



TETANUS INFANTUM. 397 

are required ; if in dysentery, or other internal inflammation, sinapisms 
should be applied over the affected part ; if the gums are swollen, and the 
eclampsia is not readily controlled by the ordinary measures, they should 
be scarified. In those dangerous cases in which symptoms of cerebral con- 
gestion continue after the eclampsia ceases, additional treatment is required. 
The child remains drowsy, does not speak, or apparently suffer in any way, 
and the pupils act less readily than in health. If this condition remains 
after the lapse of a few hours, there is probably serous efflision. All attacks 
of eclampsia, unless the mildest, are followed by a period of drowsiness, but 
the persistence of it, with symptoms which indicate hypersemia, with per- 
haps efflision within the cranium, calls for the employment of additional 
measures. Vesication should then be produced behind the ears, mild re- 
vulsives be applied to the extremities, the head kept cool, the bowels open, 
and, in certain cases, a diuretic like iodide of potassium may be advan- 
tageously employed. The utmost care should be enjoined in reference to 
the hygienic management of those who are subject to eclampsia. The diet 
should be nutritious, but bland, and all causes of excitement be studiously 
avoided. 



CHAPTER XII. 

TETANUS INFANTUM. 

Tetanus or trismus is one of the most interesting diseases of infancy. It 
is first, in point of time, in the long catalogue of fatal maladies. It occurs 
suddenly and unexpectedly in the robust as well as feeble, almost certainly 
destroying life within a few hours under modes of treatment heretofore 
employed. It is more frequent in some localities and conditions of life 
than in others. In New York it is more common than tetanus at any other 
age, or, indeed, in all other ages, since the mortuary statistics of this city 
exhibit a larger number of deaths from this disease in the first year of life 
than subsequently. Infantile tetanus occurs, with very few exceptions, in 
the new-born. 

Interesting and important as is tetanus infantum, it must be confessed 
that our knowledge of it is much more limited and imperfect than it should 
be, when we consider what great advancement has been made in patho- 
logical inquiries during the present century. Our information in reference 
to its causation, symptoms, and proper treatment is not much in advance 
of that of M. Dazille, or Dr. Joseph Clarke, who lived in the latter part 
of the last century. 

Did we better understand the pathology of diseases in the new-born, or 



398 TETANUS INFANTUM. 

could Ave more accurately ascertain the condition of organs at this age, 
doubtless we should occasionally consider those phenomena which we now 
designate as a disease per se, under the title tetanus, as symptoms of some 
other affection. But as tetanic rigidity and spasms in the new-born occur 
so abruptly, masking all other symptoms, and ordinarily ending in death 
without our knowing certainly whether or not there is any antecedent dis- 
ease, it seems entirely proper that we should recognize the state in which 
such muscular rigidity occurs with such a rapid result as an independent 
affection. This explanation is required from the fact that I have added 
to the accompanying table one case from Billard, which this observer re- 
lates under the head of spinal meningitis. In this case, an infant three 
days old was attacked with convulsions. "His limbs were rigid and 
violently bent ; the muscles of the face were in a continual state of con- 
traction." On the following day " the convulsions continued ; . . . the 
body remained rigid, and the vertebral column, which the weight of the 
trunk will cause to bend with the greatest ease in a young infant, remained 
straight and immovable whenever the child was raised." At the autopsy, 
in addition to meningeal apoplexy, which is often present in those who die 
of tetanus infantum, a thick pellicular exudation was found upon the 
spinal arachnoid. There is, therefore, a strict accordance of the symp- 
toms and history of this case with those which other observers describe as 
examples of tetanus infantum ; moreover, as a satisfactory reason for in- 
cluding this case in our statistics, certain eminent observers, as we will 
see, have reported epidemics of tetanus in which meningitis was the princi- 
jjal lesion. 

Fatal Cases. 

Case 1. Male; taken when three days old; lived sixty hours. Labatt, 

Edin. Med. and Surg. Joxir., April, 1819. 
" 2. Female; taken when three days old ; lived forty hours. Ibid. 
" 3. Taken when five days old ; lived fifty hours. Ibid. 
" 4. Taken when three days old ; lived one day. Ibid. 
" 5. Male; taken when two days old; lived two days. Billard, 

Treatise on Diseases of Children, Stewart's trans., p. 477. 
" 6. Male; taken when three days old; lived two days. Romberg. 
" 7. Male ; taken when six days old ; lived ninety-three hours. Dr. 

Imlach, Month. Jour, of Med. Sci., Aug. 1850. 
" 8. Female; taken at five davs; lived four days. Caleb Wood worth, 

M.D., Boston Med. and Surg. Jour., Dec. 13th, 1831. 
" 9. Negro; taken at seven days; lived twenty-four hours. P. C. 

Gaillard, M.D., South. Jour, of Med. and Fhar., Sept. 1846. 
" 10. Male ; taken when seven days old ; lived one day. Augustus 

Eberle, M.D., 3Iissouri Med. and Surg. Jour., 1847. 
" 11. Taken when seven days old. D. B. Nailer, N. 0. Med. Jour., 

Nov. 1846. 
" 12. Male; taken when three days old; lived one day. N. 0. Med. 

and Surg. Jour., May, 1853. 



CASES. 399 

13. Negro ; taken when three days old ; lived three days. Robert 
H. Chinn, M.D., K 0. 3Ied. and Surg. Jour. 

" 14. Taken when two days old ; died in four hours after the doctor's 
visit. Ibid. 

" 15. Taken when seven days old; lived one day. C. H. Cleaveland, 
New Jersey Med. Hep., April, 1852. 

" 16. Negro ; taken when seven days old ; death finally. Greenville 
Dowell, Amer. Jour, of Med. Sci., Jan, 1863. 

" 17. Taken when twelve days old ; lived one day. Thomas C Bos- 
well, communicated to Dr. Sims, Amer. Jour, of Med. Sci., 
1846. 

" 18. Taken when about five days old ; died at about the age of nine 
days. B. R. Jones. Ibid. 

" 19. Taken at or soon after birth ; lived two days. Dr. Sims, Amer. 
Jour, of Med. Sci., April, 1846. 

" 20. Taken at the age of six days ; lived one day. Ibid. 

" 21. Taken when three days old ; lived two days. Ibid. 

" 22. Male ; taken at the age of eight days ; died in three hours. Com- 
municated to the writer. 

" 23. Taken at the age of twelve hours ; lived two days. Communi- 
cated to the writer. 

" 24. Female ; taken when seven days old ; lived forty-five hours. The 
writer. 

" 25. Male ; taken at the age of seven days ; lived about forty-eight 
hours. Ibid. 

" 26. Female ; taken at the age of eight days ; lived three days. Ibid. 

" 27. Female ; taken at the age of five days ; lived three days. Ibid. 

" 28, Female ; taken when four days old ; lived two days. Ibid. 

" 29, Taken when six days old ; died next day. Ibid. 

" 30, Taken when five days old ; lived twenty-four hours. Ibid. 

" 31. Taken when eight days old ; lived two days. Ibid. 

" 32, Male ; taken when five days old ; lived one day. Ibid. 

Favorable Cases, 

Case 1, Negro; female; taken when three days old; recovered in a few 
days, Robert S. Baily, Charleston Med. Jour, and Rev., 
Nov. 1848, 

" 2. Negro ; taken at eleven days ; recovered in fifteen days, W, B, 
Lindsay, N. 0. Med. Jour., Sept. 1846. 

" 3. Negro ; taken when ten days old ; recovered in thirty-one days. 
P. C, Gaillard, Charleston Med. Jour, and Rev., Nov. 1853. 

" 4. Male; taken at the age of eight days; recovered in twenty-eight 
days. Ibid. 

" 5, Negro ; taken at seven days ; recovered in fifteen days, Au- 
gustus Eberle, Missouri Med^ and Surg. Jour., 1847, 

" 6, Taken when eight days old ; recovered in four weeks ; Furlong, 
Edin. Med. and Surg. Jour., Jan. 1830. 

" 7. Taken at the age of one week ; recovered in two days. Dr. Sims, 
Amer. Jour, of Med. Sci., April, 1846. 

" 8. Female; taken at the age of three days; recovered in five weeks. 
The writer. 

Period of Commencement, — Fiuckh, who saw cases of tetanus of the 



400 TETANUS INFANTUM. 

new-born in the Stuttgart Hospital, states (Heeker's Annalen, vol. iii, No. 
3, p. 304) that it began in one case on the second day after birth, in eight 
dn the fifth, and in seven on the seventh. 

Professor Cederschjold, of Stockholm, treated forty-two cases in hospital 
practice in 1834, and in these cases it usually commenced between the ages 
of four and six days. Copland says (Iledical Dictionary) that it generally 
commences in the first seven or nine days after birth, and rarely later than 
the fourteenth. Romberg states that it commences between the fifth and 
ninth days. In tw'o hundred cases observed by Reicke, in Stuttgart, in 
the course of forty-two years, it was never found to commence before the 
fifth, rarely after the ninth, and never after the eleventh day, Schneider 
says that the disease occurs ofteuest between the second and seventh, and 
rarely after the ninth day. In six cases reported by Dr. C. Levy, of 
Copenhagen, it began in two on the third day, in two on the fifth, and in 
two on the sixth. Dr. Greenville Dowell {Amer. Jour, of Med. Sci., Jan. 
1863), who has seen much of tetanus infantum among the negroes in Mis- 
sissippi and Texas, says it is almost sure to come on between the fifth and 
twelfth days after birth. In the forty cases embraced in the above table, 
the disease began as follows : 

Age. Cases. 

One day or under 2 

Two days, 1 

Three " 

Pour " 2 

Five " 6 

Six " 3 

Seven " 8 

Eight " 6 

Ten " 1 

Eleven " 1 

Twelve " 1 

Very rarely, as will be seen hereafter, tetanus begins at or so soon after 
birth, that it may be properly called congenital. 

Frequency in Certain Localities. — Tetanus infantum occurs prob- 
ably in all countries, but it does not greatly increase the mortality except 
in certain localities. Some of the British and Continental physicians, whose 
observations of disease have been ample, confess that they have seen so few 
cases that they have almost no personal knowledge of this malady. On the 
other hand, there are, or have been, places in every zone where it is or has 
been so prevalent as to sensibly check the inci-ease of population. The 
attention of the profession, more than half a century since, was directed 
to the prevalence of tetanus in the Island of Heimacy, off the coast of 
Iceland. On this island scarcely an infant escaped, while on the mainland 
scarcely one was aflfected. Heimacy, the product of volcanic action, of 
small extent and almost destitute of vegetation, supports a scanty popula- 



FREQUENCY IN CERTAIN LOCALITIES. 401 

tion. The inhabitants live chiefly on the flesh and eggs of the sea-fowl, and 
are filthy and degraded in their habits. About the year 1810, the Danish 
government deputed the landphysicus of Iceland to visit Heimacy, and 
ascertain the nature of the disease which was so destructive to the infants. 
Although this gentleman, from his brief stay, saw no case himself, he ob- 
tained interesting particulars in reference to the disease from the priests and 
parents. At this time scarcely an infant escaped. Again, according to Dr. 
Schleisner, whose report in reference to the same locality was published 
forty years later, tetanus was still the most fatal of all infantile maladies- 
Tetanus infantum is also represented as very fatal in the Island of St. 
Kilda, off the coast of Scotland. In the temperate regions of America 
and Europe cases are not frequent, except occasionally in the poor quarters 
of the cities, in foundling hospitals, and rarely in country towns where the 
conditions are favorable for its occurrence. The records of the Dublin, 
Stuttgart, and Stockholm lying-in asylums furnish many cases. In the 
town of Fulda, Germany, in 1802, Dr. Schneider saw six cases in fourteen 
days, while a midwife in the same place stated that she had seen more 
than sixty in nine years. 

But the greatest mortality from tetanus infantum is in the warm climates, 
both of the Eastern and Western Hemispheres. In the West Indies, the 
southern portion of the United States, the equatorial regions of South 
America, and in the islands of Minorca and Bourbon, it has, in many 
localities, been the most frequent and fatal of infantile maladies. 

It is an interesting fact that in the warm regions of the United States 
the victims are chiefly negro infants. L. S. Grier, M.D., of Mississippi, 
says, in the N. 0. Med. and Surg. Jour., May, 1854 : " The first form of 
disease which assails the negro among us is trismus. The mortality from 
this disease alone is very great. No statistical record, we suppose, has even 
been attempted, but from our individual experience we are almost willing 
to affirm that it decimates the African race upon our plantations within 
the first week of independent existence. We have know'n more than one 
instance in which, of the births for one year, one4ialf became the victims 
of this disease, and that, too, in spite of the utmost watchfulness and care 
on the part of both planter and physician. Other places are more fortu- 
nate, but all suffer more or less ; and the planter who escapes a year with- 
out having to record a case of trismus nascentium may congratulate him- 
self on being more favored than his neighbors, and prepare himself for his 
own allotment, which is surely and speedily to arrive." Dr. Wooten {_N. 
0. Med. and Surg. Jour., May, 1846) says : " It is a disease of fatal fre- 
quency on the cotton plantations in this section of Alabama." He has, 
however, never seen a white child affected with it. 

In New Orleans, according to the death statistics in our possession, 
which, however, relate to only one year, tetanus infantum is the most fatal 
of all diseases except phthisis. Mr. Maxwell says, in the Jamaica Phys- 

20 



402 TETANUS INFANTUM. 

iealJournal (copied m the London Lancet, April lltli, 1835): "From ob- 
servations that I have made for a series of years, ... I fouud that the 
depopuhxtiug influence of trismus neonatorum was not less than twenty- 
five per cent. It scarcely has a parallel within the bills of mortality." 
This gentleman's observations relate to the West Indies. Similar state- 
ments are made in reference to this malady as it occurs in Cayenne and 
Demerara in South America. 

While tetanus infantum prevails in regions wide apart, and presenting 
very diverse climatic conditions, there is a similarity as regards the per- 
sonal and domiciliary habits of the people who suffer most from its occur- 
rence. It occurs chiefly among those who are filthy and degraded in their 
habits, who live, either from choice or necessity, in neglect of sanitary re- 
quirements. This fact aids us in an understanding of the 

Causes. — That uncleanliness and impure air are a cause of tetanus is 
as fully demonstrated as most facts in the etiology of diseases. The atten- 
tion of the profession was forcibly directed to this cause by Dr. Joseph 
Clarke in a paper read before the Royal Irish Academy in 1789. This 
physician was in charge of the Dublin Lying-in Asylum, and had rightly 
concluded that the mortality among the new-born infants was due to im- 
perfect ventilation. Through his advice, apertures, twenty-four inches 
by six, were made in the ceiling of each ward; three holes, an inch in 
diameter, were bored in each window-frame ; the upper part of the doors 
leading into the gallery were also perforated with sixteen one-inch aper- 
tures, and the number of beds was reduced. The result of these simple 
sanitary regulations may be seen from Dr. Clarke's own statement. He 
says: "At the conclusion of the year 1782, of 17,650 infants born alive 
in the Lying-in Hospital of this city, 2944 had died within the first fort- 
night, that is, nearly every sixth child." The disease in nineteen cases 
out of twenty was tetanus. After the wards were better ventilated, namely, 
from 1782 till the time of the preparation of Dr. Clarke's paper, 8033 
children were born in the hospital, and only 419 in all had died, or about 
one in nineteen. So imj)ressed was Dr. Evory Kennedy, who at a later 
period had charge of the same asylum, with the belief that Dr. Clarke 
had discovered the true cause, and had been able in a great measure to 
prevent it, that he writes in his enthusiastic way : "If we except Dr. Jen- 
ner, I know of no physician who has so far benefited his species, making 
the actual calculation of human life saved the criterion of his improve- 
ments." The cases occurring in my own practice have almost all been in 
tenement-houses, where habits of cleanliness are not observed, and I have 
not yet seen, in the practice of others, nor heard of a case which occurred 
in the better class of doraicils. The statements of jihysicians in the South- 
ern States, who speak from extensive observation among the negroes, are 
strongly corroborative of the idea that the disease is in great measure due 
to uncleanliness and impure air. 



CAUSES. 403 

Dr. Greenville Dowell, of Texas, states that he has been able to trace 
tetanus infantum to the bedclothes, saturated with excrementitious matters, 
which are found in the negro cabins. In a paper published in the Nashville 
Journ. of Med. and Surg., June, 1851, by Prof John M. Watson, the fre- 
quency of this disease among the negroes is accounted for as follows : 

"When called to see their children, we find their clothes wet around 

their hips, and often up to their armpits, with urine The child is 

thus presented to us, when, on examination, we find the umbilical dressings 
not only wet with urine, but soiled, likewise, with feeces, freely giving oflT 
an offensive urinous and fsecal odor, combined at times with a gangrenous 
fetor arising from the decomposition, not desiccation, of the cord." 

Another cause is believed to be some irritation in the bowels, as from 
retained meconium. Observers in the Southern States and elsewhere oc- 
casionally mention this as a cause. In one case treated by myself, there 
was obstinate constipation immediately before the attack, and in another 
diarrhoea preceded, and was the only apparent cause. 

In certain cases the assignable cause is exposure to wet or cold, or to a 
variable temperature, which, it is known, occasionally causes tetanus in 
the adult. Prof. Cederschjold attributed the epidemic which he observed 
in Stockholm to a sudden change of temperature, from hot weather in May, 
to frosty in June. In a case related by Dr. P. C. Gaillard, in the South- 
ern Jour, of Med. and Pharmacy, Sept. 1846, the disease commenced as 
follows: The nurse came in with wet apron and clothes, in the evening; 
a short time after she had taken the child into her lap, it sneezed violently 
two or three times. At 10 p.m. tetanus began. In certain localities on 
the continent, where there are no parish churches, the frequent occurrence 
of tetanus has been attributed by the physicians to the practice of cai'ry- 
ing the infants to a distance to be christened, thus exposing them to the 
winds. In this city I have observed tetanus after a similar exposure. 
The influence of the weather in the production of tetanus of the new-boi'n 
is also shown by facts observed in the Stuttgart Hospital. In an aggre- 
gate of twenty-five cases treated in that institution, all but three occurred 
in the cold months. In the island of Cayenne, at a hamlet surrounded 
by mountains and dense forests, tetanus attacked only one in every twelve 
or fifteen of the infants. After a great part of the forests had been cut 
down, so as to allow access to the cold sea winds, almost all the new-born 
infants fell victims to tetanus. {Insel, Cayenne.') 

Hein relates that a citizen of Berlin lost, successively, two children 
with tetanus soon after birth. When the second child fell ill he observed 
that its cradle was exposed to a current of air. At the third accouche- 
ment the position of the cradle was changed and the infant escaped. Ex- 
posure to wet and cold has been long recognized as a cause of the disease. 
According to Sauvages, " Hie morbus hicme et cum aura humida ssepius 
advenit quam sicca restate." (Nosol. Method, vol. i, p. 531.) 



404 TETANUS INFANTUM. 

The causes of infantile tetanus, enumerated above, may be proximate 
or remote, may produce the disease by their direct effect on the system or 
by producing a pathological state which in turn leads to the development 
of the disease. There are other direct causes, namely, organic affections. 
In the bodies of those who die of this disease lesions are observed which 
doubtless result from the spasms. Again, others are found which, from 
their nature, could not be a result, and which, being observed in different 
cases, are to be regarded as direct causes. The most frequent of such 
lesions is inflammation of the umbilicus or umbilical vessels. 

Moschiou, who lived in the first century of the Christian era, stated in 
writings still extant that stagnant blood in the umbilical vessels sometimes 
produced dangerous disease in the new-born infant, and it is supposed, 
though this is doubtful, that he referred to tetanus. In modern times the 
attention of the profession was more particularly directed to this cause 
by a paper published by Dr. Colles, in the first volume of the Dublin 
Hospital Reports, in 1818. The observations published in this paper were 
made in the Dublin Lying-in Hospital during the period of five years. 
In each of these years he had witnessed from three to five post-mortem 
examinations in cases of infantile tetanus, and the lesions, he states, were 
in all much alike as follows : The floor of the umbilical fossa was lined 
by a membrane apparently formed by suppurative inflammation, and in 
the centre of this fossa was a large papilla. This papilla consisted of a 
soft yellow substance, apparently the product of inflammation, and in all 
the cases the umbilical ves.sels were in contact with this sub.stance and 
were pervious. In a few in.stances superficial ulcerations were found near 
the mouth of the umbilical vein, and occasionally the skin surrounding 
the umbilicus Avas raised. The peritoneum covering the vein was highly 
vascular, often not to a greater distance than an inch above the umbilicus, 
but sometimes as far as the fi.ssure of the liver. The peritoneum in the 
course of the umbilical arteries presented the inflammatory appearance 
in still greater degree sometimes as far as the sides of the bladder. The 
connective tissue lying along the arteries and urachus anteriorly was 
loaded with a yellow watery fluid. The inner surface of the umbilical 
vein was not inflamed, but its coats, in general, were thickened. On slit- 
ting open the arteries, a thick yellow fluid, resembling coagulable lymph, 
was found within their coats, and in all cases these vessels were thickened 
and hardened as far as the fundus of the bladder. 

Dr. Finckh, who observed twenty-five cases in the Stuttgart Hospital, 
believes that the most frequent cause was suppuration or ulceration of the 
umbilical cord. In ten of the twenty-five cases the navel was dry and 
cicatrized ; in the remainder it was either wet or swollen, with a bluish- 
red inflamed edge at the margin of the navel ; a dirty viscid pus covered 
the umbilical depression. 

Dr. Levy, physician of the Foundling Hospital in Copenhagen, at- 



CAUSES. 405 

tended twenty-two cases in that institution in 1838 and 1839. Of these, 
twenty died, and fifteen were examined carefully after death. In fourteen 
there were decided marks of inflammation in the umbilical arteries, es- 
pecially those portions lying along the urinary bladder ; in several cases 
the peritoneum over the arteries was much injected, and in three adherent 
either to the omentum or intestine by coagulable lymph ; the coats of the 
arteries were thickened, their cavities dilated and containing dark reddish- 
brown or greenish puriform matter, always fetid. Sometimes the arterial 
tunica interna was found ulcerated and absent in places, and there was 
spongy thickening of the subjacent connective tissue. In two cases the 
ulcerative process had extended from the tunica interna to the peritoneum, 
and there was a deposit of thick ichorous matter around the ulcer ; in 
one case both arteries were so softened that their coats were scarcely dis- 
tinguishable, and in another these vessels had become gangrenous. The 
appearance of the umbilicus was unchanged in four cases ; in ten the 
fundus was red and filled with puriform fluid, which quickly reappeared 
when removed, and, in general, shortly before death, the navel presented 
a greenish color. 

According to Romberg, Dr. Scholler made post-mortem examinations 
in eighteen cases of tetanus infantum, and in fifteen found inflammation 
of the umbilical arteries. These vessels were swollen near the bladder, in 
one case to the diameter of four lines, and were found to contain pus. The 
lining membrane was eroded or covered with an albuminous exudation. 
Both arteries were not always equally inflamed, and in three cases only 
one was affected. 

Schneeman found minute points of suppuration in the umbilical vein in 
eight cases (Holscher's Annalen, vol. v, p. 484, 1840), and j)U3 throughout 
the course of this vessel in one. 

The observations mentioned above were made, for the most part, in 
hospitals on the Continent ; but similar observations have been made in 
private practice. M. Boiran, of the Isle of Bourbon, says that he has 
found in every case inflammation around the umbilicus {Gazette Medicale, 
Paris, July 11th, 1841). Dr. John Furlonge {Edin. Med. and Surg. Jour., 
Jan. 1830), who resided at St. John's, Antigua, attributes the disease to 
improper dressing of the umbilicus. The same opinion is expressed by 
Mr. Maxwell, who also saw the disease in the West Indies {Jamaica Phys. 
Jour., copied into the Ijondon Lancet, April 11th, 1855). Dr. Ransom 
states, in a communication to Prof. John M. Watson {Nashville Jour, of 
Med. and Surg., June, 1851) that he has never seen a case of tetanus of the 
new-born in which the umbilicus was healthy. In a case related by Robert 
S. Baily, in the Charleston Med. Jour, and Rev., Nov. 1848, there was a 
hard scab on one side of the umbilicus, and this part was much distended. 
A discharge followed the removal of the scab, and the child recovered. 
In a favorable case, related by W. B. Lindsay, in the iV. 0. Med. and 



406 TETANUS INFANTUM. 

S^irg. Joiir., Sept. 1846, the umbilicus was tumid, and not disposed to 
heal. Dr. H. O. Wooteu (same journal, May, 1846) attributes the dis- 
ease to the condition of the umbilicus and umbilical vessels, and states 
that he has found the umbilicus gangrenous. In a case related in the 
N. 0. Med. and Surg. Jour., May 1st, 1853, the umbilical vessels were 
blocked up by purulent matter. Robert A. Chime, M.D., Brazoria, Texas 
(N. 0. Med. and Surg. Jour., Sept. 1854), believes one cause of the dis- 
ease to be improper tying and management of the umbilical cord, by which 
a diseased state is produced, which extends to the umbilicus, and thence 
to the viscera. At a meeting of the Obstetrical Society of Edinburgh, 
held April 24th, 1850, Dr. Imlach related a case in which there was a dark 
and gangrenous appearance of the integument around the umbilicus, and 
the peritoneum underneath was also dark, but not inflamed ; umbilical 
vein healthy; a little fibrin in the left umbilical artery; right umbilical 
artery much diseased ; its two inner coats apparently destroyed, and in 
their place a yellow pultaceous slough, in which pus-globules were dis- 
covered with the microscope. 

It is evident that the pathological state of the umbilicus and umbilical 
vessels described above, and which has been noticed by so many observers 
in different countries, cannot result from the tetanus. It is possible that 
the puriform substance noticed in the umbilical vessels was disintegrated 
fibrin, which had coagulated at the time of ligation of the cord, and the 
cells seen by Dr. Imlach and others may sometimes have been white cor- 
puscles still remaining from the stagnated blood. ( Virchoiv's Cellul. Pathol.) 
Still, the evidences of inflammation, in at least a part of the cases related 
above, were of a positive character. 

The belief that umbilical lesions sometimes cause tetanus infantum com- 
ports with the well-known traumatic causation of tetanus in the adult. 
This belief is strengthened by the fact, Avhich will appear further on in 
our remarks, that this disease of the new-born, from being frequent in cer- 
tain localities, has become infrequent through greater care in dressing and 
managing the umbilical cord. 

But there are cases of tetanus infantum in which there is no disease in 
or about the umbilicus. Dr. Finckh, of Stuttgart, examined the umbilical 
vessels in eleven cases without discovering any pathological change. Dr. 
Samuel B. Labatt, master of the Dublin Lying-in Hospital, published in 
the Edin. Med. and Surg. Jour., April, 1819, a paper entitled " An In- 
quiry into an Alleged Connection between Trismus Nascentium and cer- 
tain Diseased Appearances in the Umbilicus." This paper was designed 
as a reply to the essay of Dr. Colles. Dr. Labatt relates several cases in 
which there was no disease of the umbilicus and umbilical vessels, and 
others in which the disease was so slight that it probably produced no in- 
jurious effect on the health of the child. Dr. James Thompson, who spent 
considerable time in the trojiical regions, says {Edin. Med. and Surg. Jour., 



CAUSES. 407 

Jan. 1822) : " I have myself examined nearly forty cases of infants that 
have sunk under this complaint. In many I have looked at no other part 
but the navel, and have found it in all states ; sometimes perfectly healed, 
especially if the infants had lived several days ; at other times a simple 
clean wound. When death occurred on the fifth or sixth day, the wound 
was frequently in a raw state. I never yet saw it in a sphacelated condi- 
tion." This writer concludes from his observations that there are cases in 
which the cause is located elsewhere than in the umbilicus or umbilical 
vessels. In the Duh. Jour, of Med. and Chem. Sci., Jan. 1836, Dr. John 
Breen remarks : " From dissections ... we have never been able to dis- 
cover any peculiar morbid appearance which would justify us in offering 
any explanation of the pathology of the disease." In my own cases there 
was no evidence of disease of the umbilicus or umbilical vessels so far as 
could be ascertained by external examination, and in one (No. 32) a care- 
ful post-mortem examination disclosed no lesion of these parts. 

The inference from the above observations is that, although umbilical 
disease may be an occasional, probably not infrequent, cause of tetanus in- 
fantum, cases occur in which such disease is not present, and we must look 
for the cause elsewhere. From the nature of tetanus infantum, the cerebro- 
spinal axis has been from time to time examined in those who have died of 
this malady, and occasionally sufficient cause has been found in this part of 
the system. 

I have alluded in another connection to a case from Billard, in which 
tetanic rigidity occurred in an infant three days old, as the result of spinal 
meningitis. That tonic spasms not infrequently occur in older children in 
consequence of meningeal inflammation is well known, and in some of the 
reported epidemics of infantile tetanus meningitis was really present, and 
was doubtless the cause of the tonic spasms. Such an epidemic was ob- 
served by Professor Cederschjold in Stockholm, in 1834. Within a few 
months he treated forty-two cases, and, in addition to the lesions which 
are known to i-esult from tetanus, there was found in the bodies examined 
a plastic exudation at the base of the brain. Finckh, of Stuttgart, made 
twenty post-mortem examinations of those who had died of this disease, 
and in nine found spinal meningeal inflammation. 

Meningitis in the new-born infant is, however, rare, and we must regard 
it as an exceptional cause of tetanus. 

In 1846 there appeared from the pen of Dr. Sims, then practicing at 
Montgomery, Alabama, a paper designed to show that tetanus of the new- 
born is produced by pressure exerted on the nervous centre, through de- 
pression of the occipital bone. In 1848 the same writer published a second 
paper, also, in the Amer. Jour, of Med. Sci., fully enunciating his theory as 
follows : " That trismus neonatorum is a disease of centric origin depending 
on a mechanical pressure exerted on the medulla oblongata and its nerves ; 
that this pressure is the result, most generally, of an inward displacement 



408 TETANUS INFANTUM. 

of the occipital bone, often very perceptible, but sometimes so slight as to 
be detected with difficulty; that this displaced condition of the occiput is 
one of the fixed physiological laws of the parturient state ; that when it 
persists for any length of time after birth it becomes a pathological con- 
dition, capable of producing all the symptoms characterizing trismus neona- 
torum, which are instantly relieved simply by rectifying this abnormal dis- 
placement, and thereby removing pressure from the base of the brain." In 
both papers cases are narrated in support of this theory, but there are 
serious objections to this mode of explaining the occurrence of the disease. 
In the first place, if this explanation were correct, tetanus ought ordinarily 
to occur sooner, for the occiput is as much depressed previously, and in the 
majority of cases more depressed than at the period when it does actually 
commence. Pressure on the medulla would certainly be followed by im- 
mediate and marked symptoms, instead of an immunity for four or five 
days. 

Again, well-known facts in reference to the causation of tetanus infantum 
conflict with Dr. Sims's theory, as, for example, epidemics of the disease, 
its prevalence in one locality and absence in another, although no particu- 
lar attention is given to the position of the infant, the diminution of the 
number of cases by greater attention to cleanliness, of which there is 
abundant proof. Moreover, there are many reported cases of this disease 
at the commencement of which there was no perceptible displacement of 
the occipital bone. 

The inequality of the cranial bones often observed in tetanus infantum 
should, in my opinion, be explained as follows : When the new-born 
infant becomes emaciated the volume of the brain is diminished, like that 
of the trunk or limbs, and the sinking of the occipital bone simply corre- 
sponds with the amount of waste in the cerebral substance. Whatever 
the disease in the young infant, if there is much emaciation, the parietal 
bones will usually be found more prominent than the occipital. Now, in 
fatal tetanus infautum emaciation is very rapid ; those fleshy and plump, 
if the disease do not speedily end, become pinched and wrinkled. Viewed 
in this light, the occipital depression should be regarded as a result, and 
not cause, of the tetanus. 

Although we do not accept the theory which attributes tetanus infantum 
to occipital depression, there are a few cases on record in which it was ap- 
parently due to injury of the head received at birth. Dr. Sims has related 
one such case, that of a negro infant. The mistress, an observing lady, 
gave to Dr. Sims the following account of it : Its head was " mightily 

mashed The bones seemed to be loose. I got it to take a little 

boiled milk on the first day ; but it swallowed very little and very badly, 
for its jaws seemed to be locked. On the next day it took spasms and got 
stiff all over ; its hands were shut up tight, and its arms were bent uj) so 
(she placed her forearms at right angles). Every time I touched it the 



CAUSES. 409 

spasm would get worse all over, screwing up its face till it was the ugliest 
thing in the world ; and when the spasms wore off it looked as well as any- 
other new-born baby. But then the stiffness never left it, and the spasms 
kept coming and going till it died." It lived two days. 

It is evident, from the description given by the mistress, that this w^as a 
case of tetanus commencing at or so soon after birth that it seemed almost 
congenital. The apparent cause was injury of the head, occurring in con- 
sequence of protracted birth, the infant being resuscitated with difficulty 
after several minutes. 

Dr. W. C. Sutton published a similar case in the Nashville Joar. of Med. 
and Surg., April, 185.3. The infant at birth was apparently dead, but 
was resuscitated so as to live eighteen hours in a state of tetanic rigidity. 
In cases in which tetanus begins at birth, doubtless, the cerebro-spinal 
axis is in some way affected ; but in the absence of post-mortem examina- 
tions, the exact nature of the lesion is uncertain. 

It is evident, therefore, that in this disease, as in eclampsia, the cause 
in different cases may be entirely distinct. Dr. James Johnson, many 
years ago, expressed his belief in the multiplicity of causes, and he had 
been a careful and intelligent observer in the West Indies. 

The causes may be arranged in two groups, one external, the other in- 
ternal. In the first group should be placed imperfect ventilation, personal 
and domiciliary uncleauliness, and atmospheric vicissitudes ; in the second 
group, so far as ascertained, inflammation of the umbilicus and umbilical 
vessels, meningitis, and, rarely, injury of the cerebro-spinal axis during 
birth. 

The lesions resulting from tetanus infantum pertain chiefly to the circu- 
latory system. In the cases examined by Professor Cederschjold, of Stock- 
holm, already alluded to, the meningeal and cerebral vessels, and those of 
the spinal cord, the cavities of the heart, and the large vessels connected 
with the heart, were distended with blood. 

Finckh made post-mortem inspection of twenty cases in the Stuttgart 
Hospital, the bodies, at death, having been placed on their faces, in order 
to prevent any deceptive appearance from the gravitation of blood. In 
four there was no appreciable alteration in the spinal cord or its mem- 
branes. In the remaining sixteen there was effusion of blood, in consid- 
erable quantity, the whole length of the spinal cord, between the bony 
walls and the dura mater. It should be stated, however, that there was 
spinal meningeal inflammation in nine of the sixteen, though the extrava- 
sation did not, probably, result from the inflammation, but from the 
tetanus. The blood in Fiuckh's cases was very dark, sometimes fluid, at 
other times coagulated. In one case there was no change in the appear- 
ance of the brain or its membranes. In the remaining nineteen, more or 
less extravasated blood was found on the surface of the brain, or in its 
interior. The substance of the brain was healthy, as also its membranes, 



410 TETANUS INFANTUM. 

except the congestion. The only abnormal appearance observed in the 
thoracic and abdominal viscera was strong contraction of some portion of 
the intestinal tube in five cases. Dr. West says : " The most frequent 
post-mortem appearance in these cases " — referring to tetanus infantum — 
"and that which I found in the bodies of all the four children whom I 
observed, consists of effusion of blood, either fluid or coagulated, into the 
cellular tissue surrounding the theca of the cord. Conjoined with this 
there is generally a congested state of the vessels of the spinal arachnoid, 
and sometimes an effusion of blood or serum into its cavity. The signs 
of congestion about the head are less constant, though much ofteuer pres- 
ent than absent, and sometimes existing in an extreme degree ; while in 
one instance I found not merely a highly congested state of the cerebral 
vessels, but also an effusion of blood, in considerable quantity, between 
the skull and dura mater, and also a slighter effusion into the arachnoid 
cavity." Dr. Weber, of Kiel, also placed infants who had died of tetanus 
on their faces, and, without exception, found injection of the capillaries of 
the cord and spinal meninges, and extravasation of blood. M. Matus- 
zynski, according to Bouchut, " has observed effusions of blood, of variable 
quantity, in the cerebral pia mater, in the ventricles, and in the choroid 
plexuses, with considerable injection of the membranes of the brain. He 
has also seen serous infiltration beneath the arachnoid, and serous effusion 
into the ventricles, accompanied by a diminution of the consistence of the 
cerebral substance." In two cases examined by myself there was intense 
injection of the cerebral meninges and of the meninges of the upper part 
of the spine, but no extravasation was noticed. The spinal canal was not 
opened. In a third case, in which the spinal canal was opened, there was 
extravasation in addition to the congestion ; this was especially observed 
along the spinal theca. 

Dr. H. O. Wooten (iV. 0. Med. and Surg. Jour., May, 1846) states that 
he has made several post-mortem examinations, and has found the patho- 
logical appearances as uniform as in any other disease, as follows : " En- 
gorgement of the substance of the brain, and of the meninges lining the 
base of the brain, the medulla oblongata, and spinal marrow ; liver con- 



In a case related by Dr. Imlach before the Edin. Obst. Soc, April 24th, 
1850, the upper pai't of the lungs w'as healthy, the posterior portion con- 
gested, and containing many dark points ; heart and liver healthy ; small 
intestines of a light-brown color; stomach and large intestines pale; there 
had been umbilical haemorrhage. 

Romberg states that he found in a child, whose death occurred from this 
disease, such intense congestion of the veins and sinuses of the brain, that 
a slight touch, and the removal of the cranial bones, produced extravasa- 
tion of the partly coagulated and partly fluid blood. Dr. Scholler, on the 



SYMPTOMS. 411 

other hand, found actual extravasation of blood in the spinal canal in only 
one case in eighteen. 

It is seen from the above observations, that tetanus of the infant is ordi- 
narily accompanied by great passive congestion, which is especially marked 
in the cerebro-spinal axis, and that frequently extravasations occur from 
the distended capillaries. The embarrassment of respiration and the re- 
tarded' circulation of blood consequent on the tetanic rigidity afford suffi- 
cient explanation of this state of the vessels. 

Symptoms. — In many cases premonitory symptoms are absent, or are so 
slight as to escape notice. Sometimes there is a degree of fretfulness pre- 
viously, but no more than is often observed in those who continue in good 
health. The first symptom which alarms the parents, and shows the grave 
nature of the commencing disease, is inability to nurse, or evident pain and 
hesitation in nursing. Commencing with rigidity of the masseters, the 
disease gradually extends to the other voluntary muscles, and in the course 
of a few hours the muscles of the limbs, as well as of the trunk, are in- 
volved. Persistent muscular contraction, which is the pathognomonic fea- 
ture of infantile tetanus, is developed not fully in the beginning, but by 
degrees in each affected muscle, so that it is not till after the lapse of seve- 
ral hours, perhaps even a day, that the greatest amount of rigidity is at- 
tained. Therefore, in the commencement of the disease, the limbs can be 
bent, and the jaws pressed open, more readily than at a subsequent stage, 
though with manifest pain to the infant. 

During the period of maximum rigidity, the jaws are fixed almost im- 
movably, often with a little interspace between them, against which the 
tongue presses, and in which frothy saliva collects. The head is thrown 
backward and held in a fixed position by the stiffness of the cervical mus- 
cles. The forearms are flexed ; the thumbs are thrown across the palms of 
the hands, and are firmly clenched by the fingers ; the thighs are drawn 
towards the trunk ; the great toes are adducted, and the other toes flexed. 
Occasionally opisthotonos results from the extreme contraction of the dorsal 
and posterior cervical muscles. The infant can sometimes be raised with- 
out any yielding of the muscles, by one hand under the occiput and the 
other under the heels. 

The rigidity is liable to variation in its intensity, even after the full de- 
velopment of the disease. If the infant is quiet, especially if asleep, the 
muscles are partially relaxed to such an extent, sometimes in the first 
stages of the complaint, that tlie features have a placid and natural ex- 
pression, though only for a short time. There are frequent exacerbations 
in the muscular contraction, sometimes occurring without any apparent 
cause, and sometimes produced by anything which excites or disturbs the 
child. Attempts to open the lips or jaws, or eyelids, or to bend the limbs, 
blowing on the face, or even the crawling of a fiy upon it, occasions the 
paroxysm. 



412 TETAiNUS INFANTUM. 

During the paroxysm the ej'elids are forcibly compressed, as well as 
the lips, which are either drawn in or are pouting; the forehead and 
cheeks are thrown into wrinkles, and the physiognomy is indicative of 
great suffering. The unnatural positions of the trunk and limbs, which 
result from the muscular contraction, are increased for the moment; the 
head is more forcibly thrown back, and the limbs more strongly flexed. 
The muscular movements which occur during the paroxysms are some- 
times described as clonic spasms. There is indeed occasionally some 
quivering of the limbs, and yet, as I have on different occasions noticed, 
so far from the muscular action being a clonic spasm, it possesses a tonic 
character, which is at times intensified. In fatal cases the paroxysms 
occur more and more frequently until the period of collapse. 

The crying of the child affected by tetanus is never loud, however great 
the suflTering. It is variously described by writers as "whimpering" or 
" whining." It is of this suppressed character in consequence of the rigid 
state of the respiratory muscles and their imperfect movement. 

During the exacerbation respiration is suspended, or so imperfect, and 
the circulation so retarded, that the surface becomes of a deep red, almost 
livid, color. Sometimes epistaxis occurs, affording partial relief to the 
congestion, and sometimes, though less frequently, the blood forces itself 
from the congested liver along the umbilical vein, and escapes from 
the umbilicus. I have already alluded to the occurrence of meningeal 
apoplexy. 

The frequency of the pulse and respiration varies in different cases, and 
at different stages of the same case. They are often somewhat accelerated, 
but at other times are natural, or are even slower than in health. 

While the appetite of the infant, to appearance, is not diminished, the 
pain which it experiences in nursing is such that alimentation is neces- 
sarily deficient. It can be fed with a spoon for a time after it ceases to 
take food in the natural way, but artificial feeding soon fails. The milk 
placed in its mouth is in great part pressed back through the violence of 
the spasm which is induced by the attempt to feed it. 

In consequence of imperfect nutrition, the infant rapidly wastes away. 
There is no other disease except the diarrhoeal affections in which emacia- 
tion is so rapid. In a case related by Dr. W. B. Lindsay in the N. 0. 
Med. Jour., Sept. 1846, the record states that " the infant was fat three 
days before, but was now emaciated." Romberg, who saw tetanus iufiintum 
in European hospitals, and Dr. Robert H. Chinn, of Texas {N. 0. Med. and 
Surg. Jour., Sept. 1854), both speak of the rapid emaciation. The trunk 
and extremities lose their fulness, and the features become pinched. Several 
observers have noticed the appearance of miliaria in this reduced state of 
system, especially around the shoulders, and sometimes a decidedly icteric 
hue appears on the skin. 

The condition of the bowels is not uniform. They may be relaxed, 



PROGNOSIS. 413 

particularly if the disease is due to some irritation in them ; in other cases 
the stools are natural or constipated. 

It is often difficult to ascertain the state of the eyes, since attempts to 
open the eyelids bring on spasms and cause firm compression of the lids 
against each other. According to Sir Heniy Holland, one of the first 
symptoms which occurred in cases on the island of Heimacy, was strabismus, 
with rolling of the eyes. But this statement must be received with caution, 
since these cases were not seen by any physician, and the information was 
obtained from the parents and priests. If true, the proximate cause of the 
disease in Heimacy would seem to be located in the cerebro-spiual axis. 
Contraction of the pupils commonly occurs in the stage of collapse. 

Mode of Death. — Death in infantile tetanus may occur from apncea 
in the paroxysms, from extreme congestion of the cerebral vessels, or 
apoplexy ; and, lastly, it may occur from exhaustion. The last mode is, 
probably, the most frequent. 

Progistosis. — All writers till recently agree that tetanus of the infant 
rarely terminates favorably. Cullen attributes the ignorance of physi- 
cians in regard to this disease to the fact that it is so little amenable to 
treatment, that they are not usually summoned to attend those affected 
with it. In the island of Heimacy, of one hundred and eighty-five cases, 
occurring during a series of years about the commencement of the present 
century, not one survived; and in the same locality, at a more recent 
period, according to the report of Dr. Schleisner already alluded to, sixt}^- 
four per cent. died. Similar statements in regard to the mortality of 
tetanus infantum are given by physicians in the Southern States. Dr. 
H. 0. Wooten, of Alabama, says (N. 0. Med. Jour., May, 1846) that he 
has " never seen a decided case of tetanus nascentium that did not prove 
fatal ; . . . and that it is very generally deemed useless to call in medical 
aid after the initiatory symptoms are well declared." Mr. Maxwell, speak- 
ing in reference to the West Indies, says (^Jamaica Phys. Jour., copied into 
the London Lancet, K\}y\\ 11th, 1835) : "From observations which I have 
made for a series of years, ... I found that the depopulating influence 
of trismus nascentium was not less than twenty-five per cent. It scarcely 
has a parallel within the bills of mortality." Dr. D. B. Nailer {N. 0. 
Med. Jour., Nov. 1846) says : " About two-thirds of the deaths among the 
negro children are from this disease, and so uniformly fatal is it, that a 
physician is never sent for." 

Yet death does not always result. Eight of the forty cases in my col- 
lection recovered ; but a correct opinion cannot be formed from this of the 
actual ratio of favorable to unfavorable cases, since favorable cases are 
much more likely to be published. In the history of these eight cases, two 
interesting facts are noticed, which, when present, may serve as a ground 
for hope of a successful termination. These were, the age at which the 
disease began, and fluctuation in the symptoms. With two exceptions, the 



414 TETANUS INFANTUM. 

infants wlio recovered were about a week old when the initiatory symptoms 
appeared, and there were fluctuations in the gravity of the symptoms ; 
whereas, fatal cases ordinarily grow progressively worse. Yet, in favorable 
cases, the symptoms are never so severe as they become in a few hours in 
those who succumb. 

Duration in Fatal Cases. — Of eighteen cases observed by Finckh in 
the Stuttgart Hospital, fifteen died in two days, two in five days, and one 
in seven days. During the epidemic in the Stockholm hospitals, in 1834, 
where forty-two cases were treated, the disease seldom lasted more than 
two days. Romberg says : " It generally lasts from two to four days, but 
its duration is at times limited at from eight to twenty-four hours, and 
occasionally, though rarely, it extends from five to nine days." 

In thirty-one fatal cases in my collection, in which the duration is men- 
tioned — 

One lived 3 hours. 

Eleven others lived 1 day or less. 

Twelve lived 2 days. 

Four " 3 " 

Three " 4 " 

Both Underwood, who published a little treatise on diseases of children, 
in 1789, and Dr. Elstisser at a more recent date, record fatal cases which 
were unusually protracted. The one described by Underwood was treated 
in the British Lying-in Hospital, and, although all the others treated in 
this institution died by the third day, this lived six weeks ; but it is sug- 
gested by the author, that death was due in part to some other affection. 
The child treated by Elsiisser lived thirty-one days. 

Duration in Favorable Cases. — In the eight favorable cases in ray 
collection, the duration of the disease, reckoned from the time when the 
infant ceased nursing till it began again, was as follows : In one case, two 
days ; in one, a few days ; in one, fourteen days ; in two, fifteen days ; in 
one, twenty-eight days; in one, twenty-one days; and in the remaining 
case, about five weeks. 

Diagnosis. — To one who has seen this disease in the new-born, or is 
familiar with its symptoms, diagnosis is easy. The symptoms which possess 
diagnostic value are more manifest and reliable than in most other infan- 
tile affections. Permanent rigidity of the voluntary muscles," with tem- 
porary exacerbations, such as have been described above, which are induced 
by any cause which disturbs the infant — as attempts to open the mouth or 
eyelids — is pathognomonic. 

Preventive Treatment. — While tetanus infantum, if fully developed, 
is ordinarily fatal, in spite of any remedial measures heretofore used, there 
is no doubt of the efficacy and value of preventive measures, when prop- 
erly employed. This was shown by the great reduction in mortality in 
the Dublin Lying-in Hospital through the thorough ventilation introduced 



TREATMENT. 415 

by Dr. Clarke. Dr. Meriwether, of Montgomery, Ala., says (Amei'. Jour, 
of 3Ied. ScL, April, 1854) : "When the disease appears eudemically on a 
plantation, it may be arrested by having the negro houses whitewashed 
with lime, inside and out ; by raising the floors above the ground ; by 
removing all filth from under and about the houses ; by particular atten- 
tion to cleanliness in the bedding and clothes of the mother ; and in the 
dressing of the child, so as to prevent any of the matter from the umbilicus 
lying long in contact with the skin." Many physicians, especially in the 
Southern States, speak confidently of care in dressing the cord, and atten- 
tion to the umbilicus, as a means of prevention. In the N. 0. Med. and 
Surg. Jour., July, 1853, Dr. Grafton says that he has " never known the 
disease to occur in any child whose navel had the turpentine dressing." 
He uses turpentine as follows : " At the first time, a few drops of the 
undiluted turpentine are applied immediately to the umbilicus around the 
cord, and it is anointed at every succeeding dressing, the turpentine being 
diluted one-half or two-thirds with olive oil, lard, or fresh butter." This 
use of turpentine has also been recommended by other practitioners in the 
warm regions. 

Dr. John Furlonge, of St. John's, Antigua, believes (Edin. Med. and 
Surg. Jour., Jan. 1830) that no case would occur with the following treat- 
ment : "The cord, when divided, should be wrapped in clean linen. Every 
night, for two weeks, one or two drops of tinct. opii and spts. vini, equal 
parts, should be given, and castor oil, with a little magnesia, every morn- 
ing. The child must be washed in tepid water every morning, and the 
funis dressed." If this treatment is attended by the success which is 
claimed for it by Dr. Furlonge, so great care in dressing the cord is cer- 
tainly w^ell repaid in localities, as at Antigua, where a large proportion of 
the infants die of tetanus. 

Some experienced observers go so far as to assert that it is possible to 
ward off tetanus infantum after the occurrence of premonitory symptoms. 
Dr. Dowell says {Amer. Jour, of the Med. Sci., January, 1863): "Some 
with slight twitchings of the muscles, have recovered without any trouble 
by being put into a mustard-bath, washed clean, and put in a clean and 
well-ventilated cabin." 

Treatment. — In considering the effect of medicinal agents which have 
been employed in the treatment of infantile tetanus, the great difficulty 
which the child experiences in swallowing should be boi-ne in mind. With- 
out care, a considerable part of the dose is lost by the spasm of the muscles 
of deglutition, which ordinarily occurs when the spoon is placed in the 
mouth, so that, unless special attention is given to this matter, it is uncer- 
tain whether the prescribed dose is fully administered. 

The treatment employed by different physicians has been very diverse. 
Antijjhlogistic remedies were prescribed by Finckh, but every case so 
treated was fatal. He states that whenever blood was abstracted, even in 



416 TETANUS INFANTUM. 

small quantities, the symptoms were aggravated. The same result has 
followed depletory measures in the practice of other physicians. 

The internal remedies which have been most frequently prescribed are 
opiates and antispasmodics. Furlonge, in a favorable case, gave lauda- 
num, in doses of one drop every three hours, alternately with two grains 
of Dover's powdei-. Woodworth also gave one-drop doses of laudanum ; 
Eberle, one-sixth of a drop hourly. The opiate has generally been given 
in combination with an antispasmodic. The Dover's powder, given every 
three hours by Furlonge, was combined with five grains of sulphate of 
zinc. The hourly doses of laudanum, by Eberle, were combined with six 
drops of tincture of asafcetida. 

When anesthetics began to be employed in the treatment of diseases it 
was believed that they would be especially useful in cases of tetanus. 
Accordingly chloroform has been used in tetanus in the infant, with the 
effect of controlling the spasms during the time of its use, but without 
curing the disease. In Case 7 in our first table it was employed several 
times, but apparently without delaying the fatal result. The editor of the 
Netc Orleans Medical and Surgical Journal states, in the May issue of that 
periodical for 1853, that he has used chloi'oform in tetanus infantum, with 
the effect, he believes, of prolonging life. Ansesthetics certainly relieve 
the suffering of the infant, and on this account, even if they do not pro- 
long life, their judicious employment seems proper. 

The remedy which, in my opinion, is far preferable to all others, is hy- 
drate of chloral. Since the introduction of this agent into therapeutics, 
it has been employed by several physicians in the treatment of this disease 
with so good a result that it will probably supersede all other medicines 
for this purjoose. Dr. Widerhofer, of Vienna, states that he has saved 
six out of ten cr twelve by the use of chloral {London Lancet, March 18th, 
1871). He prescribes it in doses of one to two grains by the mouth, or, 
if there is great difficulty in swallowing, two to four grains by the rectum. 
Dr. F. Auchenthales relates a case (Jahrb. f. Kinderheil., N. S., IV) in 
which he gave even six-grain doses, and in nine days the disease had en- 
tirely disappeared. I have employed hydrate of chloral in only one case 
of tetanus infantum, giving it in half-grain doses, every two hours, except 
when there was profound sleep. The disease was fully developed, and the 
symptoms severe when I was called. I did not believe that the infant 
with the old remedies would live more than two days, but by the chloral 
life was prolonged nearly one Aveek. Moreover, by the use of chloral the 
suffering of the infant is greatly diminished. 

The administration of alcoholic stimulants is required at short intervals 
on account of the rapid emaciation and great prostration. 

Local treatment directed to the umbilicus in those cases in which there 
is evidence of inflammation of the umbilicus or umbilical vessels should 
not be neglected. Vesication of the umbilicus, and the application of 



INTERNAL CONVULSIONS. 417 

poultices to it, have been followed by unquestionable benefit, if we may 
believe the statement of some physicians who have made use of these 
measures. Dr. Merriwether, of Alabama, says, if there is no improve- 
ment from the medicine which he orders, he applies a blister, larger than 
a dollar, to the umbilicus, and with this treatment the child generally im- 
proves ; a remarkable statement, since so few improve at all. 

A warm foot-bath, repeated at intervals of a few hours, and stimulating 
embrocations along the spine, are proper adjuvants to the treatment. 



CHAPTEE XIIL 

INTEENAL CONVULSIONS. 

Young children are liable to temporary suspension of respiration, in- 
duced by violent emotions, especially by anger. In the midst of their 
excitement, while they are crying or screaming, their breath is suddenly 
held, as if from tonic spasm of the respiratory musclesl In a few seconds 
respiration returns and is natural. There is no stridulous inspiration or 
other unusual sound, and thei'e is no apparent ill effect, unless occasionally 
a degree of languor. External convulsions, which seem to be threaten- 
ing, seldom occur, and when they do, are ordinarily mild. Some writers 
consider dentition the predisposing cause of this arrest of respiration, by 
inducing a sensitive state of the nervous system. Such an effect of den- 
tition is possible, but certainly many infants are affected in this manner 
before the age of dentition. 

A much more serious state, and one which is recognized as a true dis- 
ease, is that variously designated by writers as internal convulsions, spasm 
of the glottis, child-crowing, laryngismus stridulus, etc. Manifest diffi- 
culties attend the investigation of the pathological state in this disease. 
There can be little doubt that it is not precisely the same in all cases. 
That there is, during the paroxysms, tonic or clonic spasm of more or 
fewer of the respiratory muscles is inferred not only from the symptoms 
pertaining to the respiratory apparatus, but from the fact that in severe 
cases there are often spasms of the external muscles, as those of the limbs 
and face. Usually, also, the movements of the eyeballs indicate spas- 
modic contractions of the motor muscles of the eyes. The occurrence of 
these contractions in parts that are visible justifies the belief that they 
occur in other parts which are concealed from view, especially as the 
characteristic symptoms cannot be readily explained except on this su])po- 
sition. Trousseau says : " Internal convulsions consist, then, principally 

27 



418 INTERNAL CONVULSIONS. 

in a spasm of tbe diaphragm and of the respiratory muscles of the abdo- 
men aud chest ; but it occurs, also, that the muscles pertaining to the 
larynx are affected with spasm at the same time with these." Rilliet and 
Barthez conclude from the symptoms that the " heart is not always a 
stranger to this internal convulsion, which, perhaps, prolongs itself even 
to the intestines." The muscles of the pharynx appear to be involved, in 
some cases, as well as those of respiration, rendering deglutition difficult. 
In one form of internal convulsions, namely, that which is principally 
referred to by writers, there is not complete arrest of respiration, but the 
inspirations, during the paroxysm, are difficult and are attended by a 
stridulous noise. Again, the respiration may cease entirely, but when it 
commences it is stridulous, and difficult for a few inspirations. In still 
another form of the disease respiration ceases, but there is no symptom or 
sign indicative of glottic spasm or of an obstacle to the ingress of air ; 
the inspirations which succeed the paroxysm are easy and noiseless. It 
has been suggested that, in these cases, there is paralysis rather than 
spasmodic contraction of the respiratory muscles, but the symptoms may 
be explained in accordance with the commonly accepted opinion, namely, 
that there is spasm of the diaphragm and, perhaps, of certain muscles 
of the chest and abdomen, while the laryngeal muscles are not affected. 
M. Herard, indeed, who has written one of the best monographs on in- 
ternal convulsions, describes three forms of the disease, according to the 
su^jposed location of the spasm, namely, laryngeal, diaphragmatic, and 
another, which consists of a blending of the two. 

Internal convulsions are not frequent in this country ; they are rare 
in France, more frequent in Germany, and quite common in England. 
They occur, with few exceptions, before the age of two years. Dr. West 
observed thirty-one cases under the age of two years, and only six above 
that age. 

Causes. — The causes of internal convulsions are not fully ascertained. 
Most observers have remarked the relative frequency of the disease during 
the period of deutitiou, and it is probable that dental evolution does ope- 
rate as a cause, by rendering the nervous system more impressible. 

Spasm of the glottis has been attributed to enlargement of the thymus 
gland, aud also to enlargement of the cervical and bronchial glands. It 
is presumed that this effect is due to the pressure of these glands on the 
par vagum, or the recurrent laryngeal nerve. It is certain, however, that 
there is no such enlargement of the thymus gland which could possibly 
produce glottic spasm, or any other form of internal convulsions at the 
age at which these convulsions commonly occur. This gland is largest in 
the new-born, and having no function after birth, it gradually becomes 
atrophied. If enlarged thymus could produce glottic sjmsm, it would 
certainly occur most frequently in the new-born. Abnormal development 
of the thymus gland was the only assignable cause of atelectasis in two 



CAUSES. 419 

infants who died soon after birth, but I have never seen a case in which a 
convulsive attack was referable to this cause. M. Herard examined the 
thymus gland in six children who died of internal convulsions, and in 
sixty who died of other affections, and was not able to discover in its 
condition any causative relation to this disease. Indeed, cases have been 
reported in which the thymus had undergone more than its usual atrophy 
at the time when the convulsions occurred (Hasse). Enlargements of 
the lymphatic glands in the vicinity of the pneumogastric or recurrent 
laryngeal nerve may possibly give rise to glottic spasm, but this is doubt- 
less an infrequent cause, if it be a cause at all, since these glands are often 
greatly enlarged in strumous and tubercular diseases without such a result. 
According to Dr. Jacobi (N. Y. Jour, of Med., Jan. 1860) : " In some 
cases, described by Dr. Friedleben, a congenital hypertrophy of the thy- 
roid gland has probably been the cause of laryngismus. The patients 
were new-born infants of normal development, and born by normal labors. 
There were no constitutional causes of the disease, but a remarkable vas- 
cular swelling of the thyroid gland. Whenever the swelling increased, 
the veins of the face and head increased in size also, the face grew livid 
and the extremities and spinal column exhibited slight tonic convulsions. 
The recurrent nerves were entirely surrounded by the glandular tissue, 
their neurilemma looked unusually red, and their functions were probably 
injured dui'ing the occasional swelling taking place during lifetime." 

The cause is occasionally located in the cerebro-spinal axis. Thus Dr. 
Coley relates a case in which an exostosis arising from the internal surface 
of the occipital bone pressed upon the cerebellum, while nothing abnormal 
was discovered in other organs. There are also striking examples in which 
the cause was located in the spinal cord. Thus Marshall Hall relates the 
following case communicated to him. A child with spina bifida was at- 
tacked with croup-like convulsions, whenever it lay so as to press on the 
tumor. 

Internal convulsions also frequently occur in rachitic softening or de- 
formity of the calvarium, since, when this is present, undue pressure occurs 
upon the brain, even by the weight of the head of the child upon the pillow. 

In some patients there is evidently an hereditary predisposition to this 
disease ; those affected belonging to families in which there is a tendency 
to convulsive maladies. Thus Toogood relates that five infants of the 
same family were affected with spasm of the glottis ; and Reid relates, on 
the authority of Powel, that of thirteen infants of the same parents only 
one escaped internal convulsions. 

The common predisposing cause is an excitable state of the nervous sys- 
tem, often- associated with impaired general health. Hence the disease is 
more prevalent in cities, where anti-hygienic conditions abound, than in 
the country. Hence, too, the frequent improvement when the patient is 
removed to the pure and bracing air of the country. The use of insuf- 



420 INTERNAL CONVULSIONS. 

ficient food, or food of a bad quality, must for the same reason be con- 
sidered a cause, as it leads to impoverishment of the blood, and renders 
the nervous system more impressible. Facts mentioned by Reid and others 
show conclusively the influence of premature weaning, and of indigestible 
or otherwise improper aliment, in the production of this disease. 

The causes enumerated above are for the most part predisposing; occa- 
sionally they are the only apparent causes, since this disease sometimes oc- 
curs when the child is perfectly tranquil, even in the midst of quiet sleep, 
or when it is at rest in its mother's arms. In other cases, and more fre- 
quently, there is an exciting cause, often trivial. Anything that requires 
exertion on the part of the infant, or that excites strong emotions, may be 
a direct cause, as anger, or any of the violent passions ; so may even cough- 
ing, or, in rare instances, attempts to swallow. One author has known it to 
occur from excitement produced by examining the throat with a spoon. In 
a case in my practice, hereafter related, it occurred whenever the infant 
cried violently. It appears from the above facts that the etiology of in- 
ternal convulsions is very similar to that of eclampsia. The same spas- 
modic muscular contraction may occur from a variety of causes. 

Anatomical Characters. — While, therefore, structural changes in 
various parts of the system may give rise to internal convulsions, this dis- 
ease, so far as ascertained, presents no anatomical characters, and must 
consequently be considered one of the neuroses. The lesions of the respira- 
tory apparatus, observed at post-mortem examinations, are either due t6 
the convulsions or are coincidences. Emphysema has sometimes been ob- 
served as a result, it is believed, of the spasmodic and irregular respira- 
tion. It was present in all of Herard's cases, and Rilliet and Barthez 
consider it common in those who die of this affection, although they did 
not observe it in any of their cases. Slight emphysema occurring in the 
upper lobes is, however, a common lesion in feeble infants, whatever the 
disease of which they die. Therefore its occurrence in internal convul- 
sions is probably more due to molecular change in the lungs, since these 
patients are cachectic, than to the irregular breathing, which is only 
momentary. 

In fatal cases of internal convulsions the blood is darker than usual, 
from an excess of carbonic acid ; the cavities of the heart and large ves- 
sels are sometimes engorged with blood ; but in other cases they contain 
no more than the normal amount. More or less passive congestion occurs 
in the internal organs ; and congestion of the cerebral vessels is sometimes 
such that transudation of serum occurs. 

Symptoms. — I have said that the symptoms vary according to the seat 
and function of the muscles which are affected. There is generally pre- 
vious ill-health. The child is drooping, and is sometimes restless for days 
before the disease appears. Finally, if the muscles of the glottis become 
affected, the peculiar crowing sound is heard now and then during inspira- 



SYMPTOMS. 421 

tion. It is observed especially when the child is crying or is agitated. It 
may be loud and well-defined from the first, but iu most patients it comes 
on gradually, so that several days elajDse before its full stridulous char- 
acter is developed. The attacks are more frequent and severe at night, in 
or after the first sleep, than in daytime. 

Under favorable hygienic conditions, the malady may pass off without 
becoming more serious. In other cases the paroxysms gradually increase 
in frequency and severity. The dyspnoea in the attack is such that the 
features are livid, the head forcibly retracted, and death seems imminent 
from apnoea. In these severe paroxysms respiration often ceases entirely 
for a moment. When the spasm ends, a deep stridulous inspiration occurs, 
after which the breathing is natural. It has been stated that internal con- 
vulsions are often associated with those, usually tonic, but sometimes 
clonic, of the external muscles. In the tonic form, the thumbs are flexed 
across the palms of the hands, and sometimes are grasped by the fingers; 
the great toes are adducted, and the other toes flexed. In severe cases, 
the hands, forearms, feet, and legs are also somewhat flexed and rigid. At 
first, the contraction ^of the external muscles is temporary, either corre- 
sponding with the internal spasm, or it is most intense at the time of the 
spasm, though commencing sooner and subsiding later. After a while, 
however, if the disease continues, the external contraction becomes more 
persistent. In severe cases, nearly every inspiration is accompanied by 
the wheezing sound, and the paroxysms of dyspnoea are excited by trifling 
causes. Anything that suddenly disturbs the mind or body may bring on 
the attack, as anger, the impression of cold, or cun-ents of air. Dr. West 
calls attention to the fact that an anasarcous condition is sometimes present, 
accompanied by albuminuria. 

If the convulsions affect other muscles, as the diaphragm or the pectoral 
and abdominal muscles, which are concerned in the respiratory function, 
while those of the larynx escape, respiration is irregular, or even suspended 
for a moment, but the stridulous laryngeal sound is absent, as there is no 
obstacle in the larynx to the entrance of air. In this form of the disease, 
the infra-mammary region may be strongly retracted during the jDaroxysm 
from tonic contraction of the diaphragm. In severe paroxysms, whether 
the spasm be laryngeal or diaphragmatic, consciousness is nearly or quite 
lost, the features may be pallid, or, if respiration be suspended, may be 
more or less livid. There is no fever in simple cases. In the paroxysm 
there is often relaxation of the sphincters of the bowels and bladder, with 
involuntary evacuations. 

The duration of the paroxysm may be a quarter, a half, or even a whole 
minute. Total suspension of respiration for even half a minute involves 
danger. In mild cases there may be but few paroxysms, and they slight. 
In other instances they occur in a severe form, almost daily for several 
weeks or even months. In the following case the muscles of the larynx 



422 INTERNAL CONVULSIONS. 

were apparently not involved. The patient was scrofulous, and has since 
had scrofulous periostitis, with necrosis and exfoliation of the surface of 
the tibia. At the time of the internal convulsions there was also a scor- 
butic or h?emorrhagic cachexia. 

Case. — On the 28th of August, 1858, a German female infant, fourteen 
months old, nursing, and having eight teeth, was suddenly seized with 
clonic convulsions. Uniformly delicate and pale, she had been in her 
usual health till the age of twelve months, when she had a single con- 
vulsive attack, and from that date had remained well till August 27th, 
when, without any premonitory symptom, she had a stool consisting of 
almost pure blood, black and offensive. On the morning of the 28th a 
similar evacuation occurred, and another in the afternoon immediately 
preceding the convulsion. Pulse 128, after the convulsion; surface cool 
and pallid ; flesh soft, but no emaciation. Turpentine was prescribed in 
two-drop doses every two hours, and laudanum in one and a half drop doses, 
repeated sufiiciently to insure quietude. 

On the 29th the pulse was 152. At 1 p.m. she had a general convulsion, 
lasting about five minutes; in the evening she had an evacuation similar 
to those passed on the preceding day. The record for August oOth states : 
"Pulse from 150 to 160; up to this time has beeo ]ilayfal, but is now 
drowsy, and, when disturbed, fretful ; manifests no desire for solid food, as 
before her sickness, but still nurses; has taken up to this time thirty-two 
drops of turpentine. When she cries or frets, she has a spasmodic attack." 
This was the' commencement of internal convulsions, with which this child 
was affected for several months. An opportunity was afforded of observing 
their character, for her excitement, when she was examined, was usually 
sufficient to produce them. After a succession of short expirations, res- 
piration ceased ; for a moment she was 'apparently insensible ; eyes closed ; 
face pale ; no frothing at the mouth. The return of consciousness and 
respiration was without any laryngeal rale ; and after the attack she seemed 
as well as before. No external convulsion and no evacuation of blood 
occurred after August 31st. 

There was gradual improvement in her health, but she continued for 
many months pallid and irritable, and subject to attacks of internal con- 
vulsions. On the 11th of April, 1859, when twenty-two months old, she 
had another attack of general convulsions. The record made on that day 
is : " Has had internal convulsions (one or more paroxysms') almost every- 
day since last August, brought on usually by crying when she is corrected 
in any way, or her wishes are refused." Again, on December 1st, 1859, it 
is stated : "Has grown considerably since the last record, and appears to 
have recovered, except that at long intervals the spasms still occur." She 
took a preparation of iron, but her recovery seemed to be due more to 
the growth and development of the body, and "to hygienic than therapeutic 
measures. 

The general health in internal convulsions is more or less impaired, ex- 
cept in mild forms of the disease, in which the convulsive attacks soon cease. 
Pallor, or a sickly and cachectic aspect, irregular, usually constipated 
bowels, poor appetite, and moroseness or irritability of temper, are common 
symptoms of severe and protracted cases. 

Diagnosis. — This disease is easily diagnosticated, unless when its symp- 



TREATMENT. 423 

toms are masked by those of external convulsions ; it may then escape no- 
tice. Spasm of the glottis may be mistaken for spasmodic laryngitis, and 
vice versa. In some of the published cases this mistake appears to have 
been made. Spasmodic laryngitis is, however, so different not only in its 
nature, but in its clinical history, that a differential diagnosis is not diffi- 
cult. It is an inflammatory disease, and is attended with febrile reaction 
and a sonorous cough ; it commences at night after the first sleep, and from 
exposure to cold — particulars in regard to which it contrasts with true spasm 
of the glottis. 

Prognosis — Modes op Death. — Statistics show great mortality in this 
disease. Dr. Reid, in a monograph on " Infantile Laryngismus," states 
that of 289 cases which he collated, 115 died. Rilliet and Barthez met 
with one favorable case in nine unfavorable : and Herard, one in seven. If 
the paroxysms are mild, infrequent, and dependent on a cause which can 
be easily removed, recovery is probable with proper treatment. The cause 
may, however, be such, even when the spasm is mild, that the case is neces- 
sarily unfavorable ; as when it is due to disease of the cerebro-spinal axis. 
We should not, however, in any case consider the patient entirely safe, 
since grave symptoms may suddenly arise, so as to change entirely the 
prognosis. Long and severe paroxysms, with lividity of the face, and symp- 
toms of suffocation, indicate an unfavorable result. The same should be 
predicted also if the infant gradually waste away, losing appetite and 
strength, especially if the face is pale and the pulse feeble. 

There are three modes of death in internal convulsions. The first is 
apnoea. The infant dies suffocated in the attack. Respiration is first ar- 
rested, and then the pulse ceases, and at the autopsy the lungs and the 
cavities of the heart are found engorged with dark blood. Death may 
also occur from the state of the brain. In such cases, passive congestion of 
the brain occurs from obstruction to the return of blood from this organ 
to the heart and lungs ; and if this congestion is not soon relieved, serous 
effusion also occurs. Death results from the congestion, and consequent 
oedema or dropsy. 

The third mode of death is from exhaustion. Repeated and severe at- 
tacks undermine the constitution ; the infant grows pale and thin gradually, 
and dies of inanition, or of some disease which this state induces. 

Treatment. — The treatment of internal convulsions has varied accord- 
ing to the theories which physicians have held in reference to its cause. 
Glandular enlargement is no longer regarded as a common cause, and there- 
fore treatment directed to its removal is less frequently employed than 
formerly. The causes of internal convulsions are in part very similar to 
those of eclampsia, and the remedies employed in the one affection are, in 
a measure, appropriate in the other. That dentition is sometimes a cause, 
is usually admitted ; and two cases, one of which occurred in my practice, 
and the other was reported to rae, clearly show the truth of this belief. The 



424 INTERNAL CONVULSIONS. 

effect of dentition is especially observed in weakly infants, when several 
dental follicles are undergoing active evolution. Thus, in one of the eases 
to which I refer, five teeth pierced the gums in the course of two weeks ; 
after Avhich no convulsive attack occurred. If, therefore, the gums are 
swollen, scarification is proper. 

In all cases of internal convulsions a careful examination should be 
made, in order to detect any appreciable cause of nervous excitation. The 
condition of the digestive organs should be ascertained, and evacuants or 
other remedies prescribed if there is evidence of their derangement. 

Sometimes the alimentation of the infant is in fault. It is, perhaps, 
bottle-fed, and the stools have an unhealthy appearance. Attention 
should be given to the preparation of its food and the times of its feed- 
ing ; or, if it nurse, the mother or wet-nurse who suckles it should have 
plain but nutritious diet, live with regularity, and give the breast to the 
infant at regular intervals. If there is a torpid state of the bowels. Dr. 
Meigs recommends " castor oil and aromatic syrup of rhubarb rubbed up 
together, three parts of the former and five of the latter." A simple 
enema answers well in such cases, and, in debilitated infants, this is pref- 
erable to medicine administered by the mouth. If there be diarrhoea, 
and it persist after the requisite changes are made in regard to the diet, 
remedies calculated to relieve it, and which are detailed elsewhere, should 
be employed. Marshall Hall states that he has ordinarily succeeded in 
curing the disease by attending to the condition of the gums and digestive 
organs. 

Since rachitis is a not uncommon cause, the child should be examined 
in reference to the rachitis manifestations, and if they appear the treat- 
ment appropriate for rachitis is required. 

In pallid and cachectic infants, tonics are indicated. The elixir of Cali- 
saya bark in half-teaspoonful doses, three or four times daily, to an infant 
of one year, is an eligible preparation. The compound tincture of bark, or 
of gentian, or the two mixed, may be given instead of the Calisaya bark. 
The preparations of iron are sometimes to be preferred. The best of these 
are the syrup of iodide of iron, tincture of iron, or the wine of iron. To 
an infant of one year the syrup may be given in doses of four drops, the 
tincture of two drops, and the wine in doses of one teaspoonful, three times 
daily. If the child is old enough, it may take iron in lozenges, as those of 
chocolate and iron. 

Antispasmodics, as asafoetida, valerian, and oxide of zinc, are often pre- 
scribed in this malady, but they are less efficacious than the general tonic 
measures which I have indicated. The salutary effect of bromide of 
potassium in eclampsia, and certain epileptiform attacks, certainly justi- 
fies the trial of this agent in internal convulsions, if they persist after the 
em])loyment of invigorating measures. 

Hygienic measures are of the utmost importance. The infant should 



TREATMENT. 425 

reside in dry and airy apartments, and should be kept much of the time 
through the day in the open air. Remarkable success sometimes attends 
this simple expedient, when medicines have entirely failed. In the London 
Med. Gazette, Jan. 14th, 1865, Mr. Robertson, of Manchester, relates five 
severe cases in which this malady was cured by exposure of the infants 
several hours daily to a cool atmosphere. These cases were treated in the 
winter months, and were kept outdoor, even during strong winds. Mr. 
Robertson has records of forty cases, all occurring between December and 
April, while he has seen no case in the summer months. As the result of 
such extensive experience, this writer recommends "the free exposure of 
the infant out of doors, for many hours daily, to a dry, cold atmosphere, 
and if the air be dry, the colder the better." Dr. Marshall Hall's ex- 
perience was similar. Says he: "The curative influence of change of air, 
and especially of the sea-breezes, is not less marked in this affection than 
in hooping-cough." Mr. Robertson recommends also, as part of the tonic 
treatment, " free sponging of the body every morning with cold water." 
In February, 1867, I attended a nursing infant, five months old, with 
internal convulsions, the paroxysms beiug attended with lividity of the 
face, and, at times, tonic convulsions of the limbs. Among the remedies 
employed was bromide of potassium, but more benefit obviously accrued 
from keeping the infant much of the time in the open air, than from the 
medicines employed. The disease passed off" in six or eight weeks. 

Unless the cause is of such nature that it cannot be removed, the 
above hygienic and therapeutic measures will, in a lai'ge projDortion of 
cases, be followed by a satisfactory result. 

The mother or nurse may abridge the paroxysm by raising the infant, 
blowing upon it, sprinkling water in the face, or gently stroking it. Dr. 
Hall recommends tickling the nostrils with a feather, to produce respira- 
tion, or the fauces, to occasion vomiting, and thereby interrupt the par- 
oxysm. Anything which produces a sudden and profound effect upon the 
system may abridge the attack. This was effected in one case, in the prac- 
tice of Dr. C. D. Meigs, by applying a cloth wrapped around ice over the 
epigastrium and the lower part of the sternum. The chief danger during 
the attack is from congestion of the brain, with eff'usion of serum or ex- 
travasation of blood. If the attack is severe, and the features congested, 
so that there is evident danger of such a result, cold applications should 
be made to the head, derivatives used for the extremities — as sinapisms, 
or mustard foot-baths — and the bowels should be speedily opened by 
enenuita. 



426 CHOREA. 



CHAPTER XIV. 

CHOEEA. 

Chorea, or St. Vitus's or St. Guy's dance, is a nervous affection, which 
is characterized by irregular and involuntary muscular movements, without 
loss of consciousness. The movements occur in the muscles of volition, 
and there is probably no one of them that may not be engaged, though 
some are more frequently affected than others. It is not known that any 
involuntary muscle is ever involved, though Sir William Jenner has ex- 
pressed the opinion that occasionally the papillary muscles of the heart 
are, so that, by their spasmodic contractions, they produce insufficiency of 
the mitral valve. This according to him, affords explanation of the fact 
that, in certain instances, a mitral regurgitant murmur is heard, which 
disappears about the time that the external movements cease. It is rare, 
however, that a mitral regurgitant murmur, heard during chorea, ceases 
when the latter terminates, and it is not improbable that in such cases 
there is, after all, a lesion of the valve, due to recent endocarditis, whether 
of a rheumatic or other origin. For a valve may be so thickened by 
recent inflammation as to cause a murmur, and after a few weeks or months 
the infiltrating substance be so absorbed that the murmur is no longer 
audible. If we admit the fact that cardiac bruits occasionally appear and 
disappear with chorea, this explanation seems to me more plausible than 
that of Jenner. Hillier says, in reference to this subject : " My own ex- 
perience leads me to doubt the existence of dynamic apex murmurs in 
chorea, that is to say, murmurs produced in hearts entirely free from 
organic change. If such murmurs ever occur, they are certainly rare. 
Organic murmurs of the heart, on the other hand, are common in chorea, 
and I am inclined to believe that organic disease of the heart often exists 
in chorea when there is no murmur." Hillier also calls attention to the 
fact that choreic movements are irregular ; but a cardiac bruit occurring 
regularly and uniformly, if not due to organic disease, Avould require rhyth- 
mical contractions of the papillary muscles to produce it. 

Age. — Chorea may occur at any period of life ; but while it is com- 
paratively rare at other ages, it is not infrequent in childhood. A large 
majority of cases are between the fifth year and puberty. Under the age 
of five years, the proportionate number diminishes as we approach the time 
of birth, and it is rarely observed in infants under one year. The young- 
est in the statistics of Hillier was three months. 

In 1870, at the Outdoor Department of Bellevue, a child was pre- 



CAUSES SEX. 427 

gented foi- treatineut, who, the mother stated, had had chorea from birth. 
The choreic movements were uo doubt observed ver}^ early in infancy, 
though the disease probably was not congenital. The following table ex- 
hibits the relative frequency of chorea at different ages during infancy and 
childhood : 

G years 6 to 10 10 to 15 

and under. years. years. 

Children's Hospital, London, Hillier, . . 81 237 104i 

M. Eufz, 10 61 118 

Outdoor department, Bellevue, ... 2 26 16 

M. See collected the statistics of 531 cases occurring in the Children's 
Hospital, Paris, and from them concludes that the maximum frequency of 
chorea is between the sixth and tenth years. Only twenty-eight of his 
cases were under six years, the remainder, 503, occuri'ing between the 
sixth year and puberty. 

Causes. — The profession are nearly agreed in regard to certain causes 
of chorea, while there is a diversity of opinion in reference to others. It 
is admitted that in a large proportion of cases there is a neuropathic state, 
which antedates and predisposes to chorea. This stateis often manifested 
in the family history by a proneness to affections of the nervous system, 
and in the individual by a highly excitable state of the emotions, so that 
he evinces joy, grief, or anger, from slight causes. 

All writers admit that there is often an inherited predisposition to chorea. 
In 27 of 48 cases of chorea, Radcliffe found that father, mother, brother, 
or sister had been or was the subject of one or other of the following dis- 
orders : paralysis, epilepsy, apoplexy, hysteria, or insanity. The children 
of parents who when young had chorea, or who exhibit proneness to ail- 
ments of the nervous system, are more liable to chorea than other chil- 
dren. Hence the fact sometimes observed, of different children in the 
same family becoming affected with chorea when they attain the age at 
which this disease ordinarily occurs. In one family, in my practice, three 
girls at different times were affected. 

Sex. — The emotions are strong in girls, since in them the nervous system 
predominates, while the muscular power is weaker than in boys. Hence 
a partial explanation of the fact which statistics fully establish, that the 
proportion of choreic boys to girls is about in the ratio of one to two and 
a fraction. I have remarked, in this city, the large proportion of cases in 
school-girls between the ages of six and twelve years; the severe discipline 
and confinement of the public schools no doubt increasing the strength of 
the emotions, and weakening the control of the will over the muscles. 

1 None over 12 years admitted. 



428 CHOREA. 



Proportion of Males to Females. 

27 to 73. Hughes's Digest of Cases in Guy's Hosp., 1846. 

138 to 303. M. See. 

25 to 40. Outddor Dc|iartmpnt, BcUevue. 

276 to 499. Clnldren'.s Hosp., Loud. We.st (Lumleian Lect.). 

46f3 to 1005 = 1 to 2.15. 

Uterine Irkitatiox. — The peculiar changes occurriug io the female 
at puberty constitute an important cause. Hence another reason of the 
excess of female cases. Dysmenorrhoea and pregnancy are causes of a 
large proportion of cases in the first years of puberty. In the male, on 
the other hand, the changes of puberty do not appear to increase the 
liability to the disease, directly or indirectly, and male cases, after the 
age of twelve years, are comparatively rare. Radcliffe states {ReynolcWs 
System of lied.) that after the ninth year, females are more liable to chorea 
than males, in the proportion of 5 to 2 ; while before the ninth year, the 
two sexes are equally liable to it. Carefully prepared statistics, however, 
notwithstanding the high authority of Radcliffe, show a preponderance of 
girls under the age of nine years, though not as great as over that age. 
In the Outdoor Department at Bellevue, of 35 patients under the age of 
ten years, 22 were girL^^, while of 20 from the age of ten years to sixteen, 
15 were girls. 

According to West (Lumleian Lect.), in 775 children with chorea, imder 
the age of ten years, treated in the Loud. Children's Ho.sp., 6-t per cent, 
were girls. 

Anaemia. — Among the most common predisposing causes of chorea is 
anaemia. It is present in so large a proportion of cases, exhibiting itself 
by pallor of the countenance and other characteristic signs, that medicines 
designed to improve the quality of the blood are among the most valued 
remedies. The peculiar neuropathic state already alluded to, which needs 
only a slight additional cau.se for the development of chorea, is, no doubt, 
largely dependent on impoveri.shment of the blood, if it is not sometimes 
due entirely to it. Among the poor of a large city like New York, or in 
hospital practice, the proportion of antemic cases of chorea is, for obvious 
reasons, much larger than would appear from general statistics. 

Rheumatism. — Dr. Copeland, M. Bouteille, and afterwards M. Germain 
See, in a more extended monograph, directed the attention of the profession 
to rheumatism as a cause of chorea. Subsequent observations have estab- 
lished the fact that rheumatism, or the rheumatic diathesis, is so frequently 
present that it obviously sustains an important relation to chorea, though 
in what manner is not fully ascertained. This relation between the two is 
more frequently observed in some countries than in others. In England 
and France, so large a proportion of choreic patients present the history 



I 



RHEUMATISM. 429 

of rheumatism either in themselves or family, that certain physicians of 
these countries believe that rheumatism is the most common cause of the 
disease. In Germany, on the other hand, according to Eomberg, in the 
majority of cases no relation can be traced between chorea and rheumatism, 
and the statistics of this city, and I think of this country, correspond with 
those in Germany. 

Various theories have been promulgated in explanation of the relation- 
ship of the rheumatic and choreic diseases. It has been suggested that 
chorea is due to rheumatism of the brain or spinal cord. This is simply 
an hypothesis, the truth or falsity of which can only be ascertained by 
carefully conducted necropsies; but the theory appears improbable in view 
of all the facts. Another theory attributes chorea to the state of the blood 
which is present in those having rheumatism or the rheumatic diathesis, as 
well as in certain other conditions. This theory is enunciated by Dr. Ogle, 
as follows: "Recognizing the frequent existence of these fibrinous deposits 
or granulations on the heart's valves in chorea, I should be much inclined 
to look upon these post-mortem appearances rather as results of some 
antecedent general condition of the blood, common also to the choreic 
condition. It is very freely recognized that this affection is frequently, in 
some way or other, connected with that condition of blood which obtains 
in what we call anaemia, or that existing in rheumatic constitutions. In 
both of these states we know that the fibrin of the blood is much in excess 
(as also it is in pregnancy, another condition looked upon as obnoxious 
to chorea) ; and in these states we know that the fibrin with which 
the blood is surcharged is very prone to be readily precipitated, either 
owing to its superabundance, or from other obscure and acquired proper- 
ties . . . upon the heart's walls or valves^ May not this hyperinosis 
be the explanation of the coincidence alluded to?" (British and Foreign 
Med.-Chir. Rev., January, 1868) — namely, the occurrence of chorea in 
those affected with rheumatism. Others still hold that chorea is the result 
of the heart disease, and not directly of rheumatism, occurring when the 
heart is affected from other causes, as well as when the lesion has a rheu- 
matic origin. This theory is plausible, and probably to a certain extent 
correct. Heart lesions, observed in children, result from scarlet fever in 
a considerable proportion of cases, though, it is true, the endocarditis and 
pericarditis of scarlet fever are believed often to have a rheumatic origin, 
occurring, in some instances, from scarlatinous i-heumatisra, but in other 
cases from scarlatinous uraemia. Occasionally, also, the heart disease 
appears to have occurred independently of both rheumatism and scarlet 
fever. Thus in a fatal case of chorea with valvular disease, related to the 
London Pathological Society, April 6di, 1869, the child was always healthy 
up to tl)e present illness (chorea), and there was no history of rheumatism 
in the family. The more observations accumulate, the more important 
does heart disease in itself appear as a cause of ciiorea. In nearly all 



430 CHOREA. 

recorded cases of fatal cliorea, which were supposed to be due to rheu- 
matism, aud iu which post-mortem examinations were made, vegetations 
have been discovered upon the valves — aortic or mitral. We shall see 
that certain eccentric causes of irritation aid in producing chorea, and 
may not the valvular disease, or the endocarditis which causes the valvular 
lesion, operate in a similar manner as a cause? We know that in the 
adult severe cardiac disease often profoundly affects the nervous system, 
perhaps in consequence of the irregular and embarrassed circulation ; and 
certainly in the child a similar cause would be likely to produce a more 
decided eflect. 

But there is an ingenious theory which attributes chorea to minute 
emboli detached from vegetations on the valves, and arrested by capillaries 
in the corpora striata, or other portion of the cerebro-spiual axis. Since 
attention was directed to this matter, emboli have been found iu one case 
iu the medulla oblongata, although this portion of the spinal axis appeared 
healthy to the naked eye. Further observations are necessary in order to 
determine how much truth there is iu this theory ; but it seems probable, 
for reasons to be stated, that if capillary embolism does cause chorea, it is 
only in a limited number of cases, and that therefore those British ob- 
servers who regard it as the common cause, have been led into error by 
the large proportion of choreic cases which are complicated by valvular 
lesions in their climate. 

That embolism is not a common cause, if indeed a cause at all, appears 
probable from the following facts : First. In many cases of chorea there 
are no vegetations, or other appreciable lesion, which could give rise to 
emboli. Secondly. Most patients recover, and some speedily, by treat- 
ment, which we would not expect if the cause were embolism. Thirdly. 
Embolism is not infrequent in the cerebral vessels of the adult, without 
the occurrence of chorea. Indeed, the conditions which produce embolism 
are much more common in adults than iu children, while the reverse is 
true as regards the liability to chorea. Fourthly. Dogs sometimes have 
chorea, but the injection of minutely divided fibrin or other substance in 
the veins of the dogs is not followed by chorea as one of the phenomena. 
Fifthly. Were capillary emboli the cause, we would expect to fiud an 
occasional embolus in the larger vessels of the brain, so as to be appre- 
ciable to the naked eye ; but I find no examples of this in all the recorded 
autopsies which I have been able to consult. Moreover, it seems improb- 
able that capillary embolism, when producing no lesion appreciable to the 
naked eye, would so arrest the circulation, and disturb the function of the 
brain or spinal cord, as to cause chorea, for the ill effects of such an ob- 
struction would be likely to be obviated by the numerous anastomoses. 

It is obviously better, in the present state of uncertainty regarding the 
exact relation of rheumatism and valvular disease to chorea, to postpone 



FEIGHT IMITATION. 431 

the acceptance of any theory till the minute anatomy of chorea has been 
as fully investigated as has its clinical history. 

Fright. — A not infrequent exciting cause of chorea is sudden and pro- 
found emotion, especially fright. All statistics give fright as the cause of 
a certain proportion of cases, though there are usually other potential 
co-operating causes, as ansemia or valvular disease. Fright was stated as 
the cause of chorea in 31 of the 100 cases occurring in Guy's Hospital, 
reported by Hughes, or in nearly one in three. But the statistics of other 
observers do not give so large a proportion of cases originating in this 
way. Chorea may commence within a few hours after the fright, or not 
till the lapse of several days (eight or ten). If several weeks have passed 
since the fright, as in some reported cases, the chorea is probably due to 
other causes. In rare instances, chorea is said to have been caused by 
sudden and excessive joy. 

Imitation. — Under unusual circumstances, especially in a state of great 
mental excitement, imitation has been known to cause a form of chorea. 
Hecker describes an epidemic of it, occurring in the middle ages, and 
spreading through villages. In modern times it is rare that chorea 
originates from this cause, nevertheless occasional examples have been 
recorded. 

But the disease which occurs from imitation differs from the ordinary 
form, and has been termed chorea major ; while chorea proper, which is 
the subject of this article, is sometimes designated, in contradistinction, 
chorea minoi*. 

In chorea major the patient leaps, dances, or whirls like a top. It has 
its origin commonly in religious excitement, and spreads by imitation 
almost in the manner of an infectious disease. The epidemic of the 
middle ages was a chorea major. I have not been able to find any ac- 
count of cases spreading by imitation, in modern times, which were not 
examples of the same form of chorea. Thus in the Edin. Jour, of Med. ■ 
and Surg, for July, 1839, there is a clear description of chorea major, 
occurring successively in five children in the same family. Dr. Dewar, 
the attending physician, states that one of the children whom he was 
called to see was sitting near the fireplace, when her head dropped on her 
chest, and she appeared to doze some minutes. In the meantime the res- 
piration became a little accelerated, the face altered and flushed, the eyes 
wild. In less than one minute she bounded from one extremity of the 
apartment to the other, leaping over chairs, a chest, and then throwing 
herself upon the floor; she attempted to stand upon her head, rolled 
upon the floor, and then, rising, ran with extreine swiftness in the room, 
till she finally fell again on the floor, where she remained motionless some 
minutes. Then, recovering, she noticed those who surrounded her, and 
asked of her sister a toy, which she had allowed to fall. The whole 
paroxysm lasted twenty minutes. 



432 CHOREA. 

Obviously, the symptoms of chorea major difTer materially from those 
of chorea proper, and it is a question whether it should have the same 
generic name. It is a curious and interesting disease in its psychical and 
pathological aspects, but it is so rare in modern times that a knowledge of 
it is of little practical importance. 

Intestinal Irritation. — In rare instances intestinal worms cause 
chorea, though in these cases there have usually been some co-operating 
causes. The following is an example, related by Mr. Ogle {Lond. Medico- 
Chir. Bev., Jan. 1868) : " Ellen L., 9 years old, had been under treatment 
about a month with chorea, rheumatism, and worms. She had not slept 
in four days, and there was constant spasmodic movement of the body 
and face. Her general condition was very unpromising. As she had 
passed portions of a tapeworm at intervals during the last three months, 
one drachm of the oleum filicis maris was administered in mucilage, which 
caused the expulsion of the entire worm. From that time she fully and 
rapidly recovered from the chorea, though a mitral murmur remained." 

Lesions of Brain and Spinal Cord. — Nearly all standard authors 
who reject embolism as a cause of chorea believe there is no anatomical 
cause of the disease located in the cerebro-spiual axis. In other words, 
they regard chorea as one of the neuroses. This view is probably, in the 
main, correct ; but experiments, and also occasional cases, establish the 
fact that if not true chorea, at least choreiform movements, now and then 
result from a structural affection of the nervous centres. 

Experiments on certain of the lower animals demonstrate that irregular 
muscular movements may be produced by traumatic injury of certain 
IDortions of the cerebro-spiual axis, as the corpora quadrigemiua, crura 
cerebri, pons Varolii, crura cerebelli, thalami optici, parts of the medulla 
oblongata, and the upper portion of the spinal cord. Pressure on the 
projecting part of the medulla oblongata of an acephalous monster also 
causes convulsive movements. At the meeting of the New York Academy 
of Medicine, April 20th, 1871, Professor Post related the case of a child 
who was struck with a billet of wood, over the occiput, and chorea fol- 
lowed, due, in all probability, to the injury of the brain which resulted. 

If irregular muscular movements, choreic or choreiform, result from 
traumatic injury of certain portions of the nervous centres, may they not 
also occasionally occur from lesions of the same parts produced by dis- 
ease? Sir Benjamin Brodie relates the case of a choreic girl, dying in St. 
George's Hospital (Loudon Lancet, Dec. 19th, 1840j, in whom, after a 
careful post-mortem examination, the only morbid appearance observed 
was a tumor the size of a hazelnut, connected with the pineal gland. Dr. 
Broadbent described another case before the London Pathological Society 
(vol. xiii, page 21:6, Transaction.^), in which a tumor was found arising 
from the centre of the spinal cord ; and Chambers one in which tubercles 
were imbedded in the cord. Romberg quotes from Frerichs a case in 



r 



ANATOMICAL, CHARACTERS. 433 

which the medulla oblongata was pressed upon by au enlarged odontoid 
process ; and Dr. Aitken ( Glasgow Med. Jour., vol. i) one in which the 
specific gravity of the thalamus opticus and corpus striatum was greater 
on one side than on the other. Rilliet and Barthez relate other similar 
cases, and add : " We may conclude, from these different cases, that there 
exist two species of chorea: the one essentially a simple neurosis, while 
the other depends on an alteration of the encephalo-rachidian system. 
In a word, it is of chorea as of convulsions, that it is sometimes idiopathic, 
sometimes symptomatic." Still, the cases in which it is symptomatic are 
so few, that it is proper to consider chorea, as it ordinarily occurs, one of 
the neuroses until the microscope detects some anatomical cause in the 
cerebro-spinal system of which we are now ignorant. 

Anatomical Characters. — So far as ascertained, choi-ea has no cer- 
tain anatomical characters. As we have seen, lesions are sometimes present 
which probably sustain a causative relation to the disordered muscular ac- 
tion, and others are sometimes observed which are neither a cause nor 
result, their presence being a coincidence. But there are two lesions which, 
though often absent, have been observed in so large a proportion of fatal 
cases that they are justly regarded as an occasional result when chorea is 
severe. Dr. Hughes, of London, collected records of the post-mortem ap- 
pearances of 14 cases, with the following result as regards the cerebro- 
spinal axis : Brain, 14 cases : healthy, 4 cases ; only congested, 3 cases ; 
softened in part or entirely, 6 cases (some of these also congested). In 
some of these cases those occasional results of congestion, namely, transu- 
dation of serum and extravasation of blood, in greater or less quantity, 
were also observed. Spinal cord : healthy, 3 cases ; congested, 2 cases (one 
slightly, in the other the engorged vessels were large and numerous) ; 
softening in medulla oblongata, 1 case ; softening opposite fourth and fifth 
vertebrae, 12 cases. In one there was soft, in another firni adhesion of the 
spinal meninges, and in one it is stated that the rachidian fluid was opaque. 
Of sixteen fatal cases of chorea occurring in St. George's Hospital, " con- 
gestion (more or less complete) of the nervous centres (brain or spinal 
cord, or both) was met with in six cases." There was softening of certain 
parts of the brain in one case, and of the spinal cord in another. (Ogle, 
Brit, and For. Medico- Chir. Rev., Jan. 1868.) Other statistics of the an- 
atomical character of fatal chorea correspond, in the main, with those of 
Hughes and Ogle. These lesions are probably not present in ordinary 
cases, occurring only when the choreic movements are so severe that the 
patient is deprived of needed repose, and the important functions of the 
economy, as the circulation and nutrition, are seriously disturbed. 

The post-mortem examination of other parts besides the cerebro-spinal 
axis furnishes a negative result, if we except such affections as have been 
ascertained to act as causes of chorea. What portion of the nervous centre 
is chiefly involved in chorea is uncertain. Some, as Sir Benjamin C. 

28 



434 CHOREA. 

Brodie (London Lancet, Dec. 19th, 1840), consider chorea a disease of the 
nervous system generally, while others have attributed it to disease or dis- 
order of a certain part, as the corpus striatum, cerebellum, etc. Finally, 
it is stated that, in late experiments on choreic dogs, the movements do 
not cease when the spinal cord is severed from the brain, nor also on di- 
vision of the posterior roots of the spinal nerves. (Legros et Onimus, 
Rech. sur les mouvements choreiformes du chien, Acad, des Sci., 9 Mai, 
1870, Lyons Med. Jour., June 5th, 1870.) In these cases, therefore, the 
part of the axis which is in fault would appear to be solely the spinal 
coi-d. 

Symptoms. — Chorea is partial or general. It is partial when it affects 
a few muscles, or groups of muscles, as those of one arm, the face or neck, 
or of one eye. It is designated general, when all the limbs, and certain 
of the muscles of the face and trunk, are involved. Statistics show that 
partial chorea occurs more frequently on the left than on the right side, 
and in general chorea the movements on the left side are apt to predomi- 
nate. The commencement is usually gradual. Even when finally chorea 
becomes general, certain muscles only are affected in the commencement in 
ordinary cases. The child in whom this disease is about to begin is ob- 
served to be fretful and impatient from slight causes, and the irregular 
muscular action at first is apt to be misunderstood by the parents, who 
reprimand him for his supposed fidgety habit. In exceptional instances, 
especially when the cause is a sudden and profound emotion, the com- 
mencement is abrupt, and the disease is severe and general from the first. 

In a majority of cases the muscles which are primarily affected are those 
of the face, neck, fingers, or hand on the left side. Sydenham erred, 
unless the clinical history of chorea has changed during the last two cen- 
turies, when he stated as the common fact that a tottering gait is its first 
manifestation ; but now and then such a case does occur. Wherever the 
choreic movements first appear, other muscles are soon involved, so that in 
the course of a few weeks, sometimes of a few^ days, iill the muscles that 
participate are engaged. 

A muscle affected by chorea alternately contracts and relaxes, but less 
forcibly and rapidly than in eclampsia, and the movement is partly con- 
trolled by volition. This produces an unsteady and tremulous action of 
the part, whether a limb, the neck, or face ; which at once arrests atten- 
tion, and indicates the nature of the disease. The result is similar, as 
regards the muscular action whether the patient wills a movement, or 
attempts to control those Avhich chorea produces. 

If the case is of ordinary severity, the movements continue with but mo- 
mentary intermissions, except during sleep, when they ordinarily cease. In 
grave cases patients are often deprived of the proper amount of sleep, in 
consequence of the sevei'ity and persistence of the muscular action, and in 
exceptional instances, especially when the result is fatal, the movements 



SYMPTOMS. 435 

continue in sleep, but the sleep is not sound, and is frequently interrupted. 
In profound sleep, the muscles are probably always in repose. 

The older writers have left us graphic descriptions of those diseases which 
have striking external manifestations, though often with somewhat of ex- 
aggeration. Sydenhtim says of chorea : " The patient cannot keep it (his 
hand) a moment in the same place ; whether he lay it upon his breast, or 
any other part of the body, do what he may, it will be jerked elsewhere 
convulsively. If any vessel filled with drink be put into his hand, before 
it reaches his mouth, he will exhibit a thousand gesticulations, like a moun- 
tebank. He holds the cup out straight, as if to move it to his mouth, but 
has his hand carried elsewhere by sudden jerks. Then perhaps he contrives 
to bring it to his mouth, and if so, he will drink the liquid off at a gulp, 
just as if he were trying to amuse the spectators by his antics !" 

In severe general chorea a similar description is applicable to the move- 
ments of the legs and features. Grimaces and distortions of the features 
occur, while the gait is halting and unsteady, or it is impossible to walk, 
and the patient lies or sits. The speech is slow, thick, and indistinct, in 
consequence of the muscles of the tongue and larynx becoming engaged, 
and even mastication and deglutition are rendered difficult. The imper- 
fect speech in chorea is attributed partly, however, to the impairment of 
the mental faculties. Chorea, except in mild cases, is accompanied by 
other symptoms referable to the nervous system. More or less impairment 
of the mental faculties occurs in severe and protracted chorea, exhibiting 
itself in dulness or apathy. The countenance sometimes presents in ag- 
gravated cases almost the appearance of idiocy. The muscles, instead of 
becoming hypertrophied, and more powerful by their frequent contraction, 
grow softer, more flabby, and weaker. Indeed, a partial paralysis some- 
times results, so that a degree of numbness is experienced in the affected 
part, and the limb when raised cannot be sustained. Pain is not a symp- 
tom of chorea, but fugitive rheumatic or neuralgic pains are sometimes 
experienced. Derangement of the digestive function, exhibited by a poor 
or capricious appetite, constipation, etc., are common. 

The urine of choreic patients has been examined by Drs. Walsh, Ford, 
Bence Jones, Handfield Jones, Radcliffe, and others, and its elements have 
been found in most cases to vary from their normal quantity. Dr. Hand- 
field Jones read a paper before the Clinical Society of London, in 1871 
(^London Lancet, July, 1871), on two cases of chorea in which he had made 
careful chemical analysis of the urine, with the following result : During 
the height of the disease the amount of the urine was much in excess of 
what it was when the disease had ceased ; the amount of urea excreted 
during the choreic period was enormous; the amount of phosphoric acid 
excreted when the choreic symptoms were at their maximum was excessive, 
but the quantity was less than the average during convalescence; a mode- 
rate amount of uric acid during the disease, but none upon recovery. 



4S6 CHOREA. 

Prognosis — Course, — Chorea, though obstinate aud often incurable iu 
adults, usually terminates favorably iu children in three or four months. 
Bouchut considers its ordinary duration at from thirty to fifty days, which 
is certainly shorter than the average duration in this country, except as 
the disease is materially abridged by treatment. The same author states 
that it may continue only twenty-four hours, or some days, as he has ob- 
served in the convalescence from scarlet fever. But tremulousness of the 
muscles occurring in the state of weakness following a grave disease, and 
abating as the general health is restored, I should not consider as properly 
choreic, any more than that occurring from over-fatigue As the choreic 
movements gradually increase in the initial period till a certain maximum 
is reached, so their decline is gradual. There are temporary variations 
also throughout the disease as regards the extent of the movement, which 
are aggravated by mental excitement, bodily fatigue, certain functional 
derangements, especially of digestion, and sometimes from causes which 
are not apparent. 

Though, as a rule, chorea in children ordinarily terminates favorably 
under different, and even injurious, modes of treatment, there are excep- 
tional cases. Romberg relates the history of a patient who died at the age 
of seventy-six years, having had chorea since the age of six years. Iu 
chorea limited to a few muscles, or a group of muscles, the prognosis is 
more doubtful than when it affects a large number, since in the former 
case the cause is more apt to be some lesion of the cerebro-spinal axis. 
Thus chorea involving only certain muscles of the neck or of the eyes is 
sometimes due to this cause, and is then very obstinate. 

Again, observations demonstrate that chorea, when at first in all proba- 
bility strictly a neurosis, but of a protracted and grave character, may 
give rise to a central organic disease. This is the course of most of the 
fatal cases, congestion, softening, or other lesion occurring over a greater 
or less extent of the nervous centres. Radclifi'e has known cerebral men- 
ingitis to supervene in two instances. With the occurrence of a lesion of 
the cerebro-spinal axis new symptoms arise, such as headache, convulsions, 
delirium, and paralysis, and the choreic movements cease or continue, 
according to the nature of the lesion. 

Chorea, like certain other diseases,, either of a nervous character, or 
having a nervous element, is more or less modified by intercurrent inflam- 
matory and febrile affections. The oft-quoted expression from Hippocrates, 
febris accedens solvit spasmos, observations show to be founded in fact, the 
most frequent example of which occurs in pertussis. In chorea the move- 
ments, as a rule, are either rendered milder or they cease as long as the 
febrile excitement continues ; but there are exceptions, and the subsequent 
course of the disease is not modified. 

Diagnosis. — This is not difficult in ordinary cases. The irregular move- 
ments, with consciousness preserved, enable us to make a diagnosis at sight. 



TREATMENT. 437 

In its commencement, and when it continues in an unusually mild form, 
chorea might be overlooked by the physician, as it often is by the parents, 
the movements being attributed to a fidgety habit; but medical advice is 
seldom sought till the movements are so pronounced that it is impossible 
to err, except through gross ignorance or carelessness. 

It is important to determine when chorea merges in an organic disease, 
and also whether there is a local cause of the chorea. A careful and 
intelligent study of the symptoms and history of the case is requisite in 
order to a correct diagnosis in these particulars. 

Treatment — Regimenal. — As chorea in a large proportion of cases 
occurs in a state of ansemia, and the vital forces are ordinarily more or 
less reduced, obviously the regimen should be such as invigorates the sys- 
tem. Fresh air and outdoor exercise, active or passive, according to cir- 
cumstances, with the avoidance of undue excitement, are requisite; and 
the diet should be nutritious, but plain and unirritating. The various 
functions should be preserved so far as possible in their normal state. In 
exceptional instances, when the choreic movements are violent, the patient 
should lie in bed, and the muscular action, if so constant and excessive as 
to deprive him of the requisite sleep, should be restrained by light and 
well-padded splints. 

Medicinal. — Sometimes among the co-operating causes is one of a local 
nature, which is susceptible of removal, as a carious and painful tooth, 
intestinal worms, etc., and measures calculated to efi*ect this are obviously 
required. Allusion has already been made to a case in which the employ- 
ment of the oleum filicis maris, and the expulsion of a tapeworm, effected 
a speedy cure. 

The remedy which has been most employed in chorea, and which in 
consequence of the ansemia is plainly indicated in a large proportion of 
cases, is iron. It does not interfere with the employment of other remedies 
which have a more specific effect. Nearly all the ferruginous preparations 
have been prescribed in different cases with benefit. Radcliffe, who justly 
ranks as one of the first authorities in nervous diseases, gives the prefer- 
ence to the iodide of iron, believing that iodine, as well as iron, exerts a 
curative influence. I have of late inclined to the use of the ammonio- 
citrate, as it is easy of administration in simple syrup, and is well tolerated. 

Arsenic, highly extolled by Romberg and others, is a remedy of un- 
doubted value. It is conveniently given in Fowler's solution. It should 
be administered in doses of three to five drops three times daily, after the 
meals, as in the treatment of cutaneous or other aff*ections. Radcliflfe has 
administered by subcutaneous injection Fowler's solution, diluted with an 
equal quantity of water, in a few cases of obstinate local chorea, with a 
satisfactory result. An adult with choreic movements in one side of the 
neck of nine years' duration was nearly cured by fourteen injections, 
employed at intervals of a few days, the quantity employed being increased 



438 CHOREA. 

gradually from three to fourteen minims of the solution. Another remedy 
of undoubted value is strychnia. Trousseau, who prescribed it iu most 
cases, and highly extolled it, employed the following formula : 

R. StrychniiP sulphat., gr. j. 
Syr. siniplic, 5ijss. Misce. 

A child of the ordinary age, say ten years, takes at first a teaspoonful 
twice or three times daily, at uniform intervals, and the dose is gradually 
and cautiously increased until it begins to produce physiological effects. 
Strychnia, when employed to the extent of causing some rigidity, is more 
efficient as a remedy, but smaller doses have been found useful. 

Professor Hammond {Diseases of the Nervous System, page G17) says: 
" My main reliance is on strychnia, which, I think, should be given in 
gradually increasing doses, somewhat after the manner recommended by 
Trousseau. . . . This plan of treatment certainly shortens the duration of 
the disease very materially, and causes great improvement iu the general 
health of the patient. Sometimes the effect is so well marked, and is so 
immediate, that it is not necessary to increase the doses to the extent of 
causing muscular cramps, but generally the full therapeutical eflfect of the 
drug is not obtained till the calf of the leg or the nucha has slight tonic 
spasm. I have never seen the slightest ill-consequence follow this mode 
of treatment, and the doses are increased so gradually that, with careful 
watching, danger need not be apprehended." Dr. Hammond has treated 
thirty-two children with this agent without a single failure. 

But as chorea terminates favorably with smaller and safe doses, even if 
the time required is longer, it does not seem proper to recommend its em- 
ployment to the extent of producing physiological effects for general prac- 
tice. Bouchut, speaking upon this point, says: ''But, with these precau- 
tions, strychnia is extremely dangerous, for I have seen, at the Hopital des 
Enfants Malades, a young girl of thirteen years die in tetanus," produced 
by an increased dose of this drug (article on Chorea). Dr. West, in his 
Lumleian Lectures, also says: "I have seen one instance in which its em- 
ployment, while it failed to benefit a somewhat severe case of chorea, was 
followed by two attacks of violent tetanic convulsions, which nearly proved 
fatal;" and he adds, "The twitching of the limbs of itself prevents our be- 
coming aware of the dose being excessive, and a child's inability to de- 
scribe its sensations deprives us of another." For such reasons, Dr. West 
does not favor the employment of this agent. Still, any agent may be 
given in an overdose, and it is not difficult to prescribe strychnia in a dose 
which will be efficient and yet safe for children at the age at which chorea 
ordinarily occurs. I have employed bromide of potassium in a few cases, 
but with so little benefit that I am not inclined to continue its use for this 
disease. Others have not been more successful. However efficacious the 
bromide may be in epilepsy, it does not appear to be a remedy for chorea. 



TREATMENT. 439 

Cimicifuga, first employed by Jesse Young of this country, is highly 
esteemed by Philadelphia physicians in the treatment of chorea. I have 
employed the fluid extract in doses of half a drachm, increased to one 
drachm, for a child from six to ten years of age, and though it benefits 
some cases, it has no appreciable effect either in moderating the move- 
ments or abridging the duration of others. 

Ether, asafoetida, valerian, musk, the oxide and sulphate of zinc, tur- 
pentine, tartar emetic, opium, and numerous other remedies, have been 
recommended, and some of them have seemed useful in certain cases. In 
this city sulphate of zinc has been frequently employed as a remedy for 
chorea, and in gradually increasing doses till more than twenty grains 
were administered three times daily, but it has not appeared, so far as I 
have been able to ascertain, to exert any marked influence either on the 
severity or duration of the choreic movements. Justice, however, requires 
us to state that Dr. West, who has written most recently on the nervous 
disorders of children, thinks that it has been beneficial in certain cases in 
which he has employed it, and regards it on the whole as the best remedy. 

RadcliflTe, who has had ample experience in the treatment of nervous 
afiections, writes : "In an ordinary case of chorea the plan of treatment 
which I have now adopted as a rule for some time is to give cod-liver oil, 
in conjunction with hypophosphite of soda, making the draught contain- 
ing the latter salt the vehicle for the administration of the cod-liver oil." 
Sometimes camphor or the sesquicarbonate of ammonia is added. Of more 
than thirty cases treated in this way, the average duration was under three 
weeks. Radclifie began to prescribe these remedies on theoretical grounds, 
believing that phosphorus and cod-liver oil were required to restore "nerve 
tone," and the result of this treatment has certainly been such as to com- 
mend it to the profession. To children he gives from five to eight grains 
of the hypophosphite of soda three times daily. 

In the large class of children's diseases at Bellevue, where probably 
more choreic cases are treated than in any other institution in this country, 
and where therefore a most excellent opportunity occurs of observing the 
eflfects of medicine, we give the preference to the arsenical treatment of 
Romberg, or the cod-liver oil and hypophosphite treatment of Radcliffe, in 
some cases combining the two modes of treatment, and in some alternating 
them. 

In those sevei'e cases in which the choreic movements prevent the proper 
amount of sleep, a moderate dose of hydrate of chloral may occasionally 
be advantageously administered. 

Electricity has been many times employed in the treatment of chorea, 
and though some, chiefly electricians, believe that it has a curative effect^ 
others, and the majority, fail to see any material benefit from its use. 

Cold general baths, the shower-bath, frictions along the spine, etc., have 
been employed ; but the local treatment which has so far been most sue- 



440 INFANTILE PARALYSIS. 

cessfii], and which promises to supersede all others, consists in the applica- 
tion of ether spray over the spine. About two ounces of ether are em- 
ployed at each sitting, the spray being applied from an atomizer up and 
down the whole length of the spine if the chorea is general. The opera- 
tion, which occupies from ten to fifteen minutes, should be repeated daily 
or every second day. A considerable number of cases have been reported, 
in which the spray has apparently had a good effect in controlling the 
disease. 



CHAPTER XV. 

INFANTILE PAKALYSIS. 

Paralysis in young children, especially infants, is in most instances 
due to causes which seldom produce it in adults. The principal cause of 
it in the adult, namely, cerebral apoplexy, is indeed rare in children. 
Paralysis in children has the following recognized causes : 1st. A change 
in the blood, not fully understood, induced by certain grave diseases, as 
diphtheria, typhoid fever, measles, scarlet fever, etc. 2d. Reflex influence. 
The function of some part of the system is in some way disturbed, and 
paralysis occurs in certain muscles, maybe at a distance from the cause, 
and it disappears when that cause is removed, unless it has continued too 
long. The only rational explanation is found in the fact of a continuous 
connection between the local cause and the paralyzed muscles through 
the afferent and efferent nerves, and the nervous centres. 3d. Compression 
or injury of a nerve-trunk. These cases are rare. Pressing of the portio 
dura by the blades of forceps during birth, described in the next chapter, 
is an example. 4th. An anatomical alteration in the muscular fibres, the 
nerves and nervous centres remaining unaffected. This has been desig- 
nated myogenic paralysis. This form of paralysis is probably often of a 
rheumatic nature. Paralysis of the face or other portions of the surface, 
which sometimes occurs in children and adults from prolonged exposure to 
cold winds, is of this nature. 5th. Some anatomical change in the nervous 
centres, as congestion, hiemorrhage, inflammation, emboli, compression and 
laceration of brain, whether by tumors, inflammatory products, or other 
causes, etc. If there is hemiplegia the presumption is that the disease 
causing it is cerebral ; if paraplegia, that it is spinal. The following is an 
interesting example of hemiplegia. The case was related by me, and the 
specimen presented to the New York Pathological Society. 

Maggie, aged 2 years 8 months, was admitted into the Catholic Found- 
ling Asylum about the 1st of September, 1874. She seemed to be in good 



CASE. 441 

health aud was plump and well-developed, aud her mother stated that she 
had had no serious sickness. After her admission she continued well, 
having the usual appetite, amusing herself through the day, and present- 
ing no symptoms to attract attention till December 6th. On the evening 
of December 5th she ate her supper as usual, and was placed in her crib, 
apparently in perfect health. At 3 a.m., the sister who was in charge of 
the ward, found her in severe general eclampsia. Immediately, in addi- 
tion to the usual local treatment, she administered five grains of bromide 
of potassium, and this was repeated at intervals till six or seven doses 
were administered. Nevertheless, the spasmodic movements continued, 
with more or less violence, till H p.m., and in the muscles of the neck 
somewhat longer. 

On my arrival at the asylum, at about 6 p.m., I found her lying quietly, 
rather stupid, but easily aroused. Her vision was evidently good, and 
she was conscious ; the pupils responded to light, and the direction of the 
eyes was normal ; pulse 104, no cough, and respiration natural ; tempera- 
ture, as ascertained by the thermometer in the axilla, also normal. There 
was no apparent paralysis of the muscles of the face, but the right arm 
and leg were paralyzed, though the paralysis was not complete. The 
great toe flexed on tickling the sole of the foot, but the foot itself had 
little or no motion, and on my attempting to flex the leg, which was ex- 
tended, some rigidity of the muscles was observed. At times the patient 
produced slight movement of the thigh upon the trunk. The muscles of 
the right upper extremity were more flaccid than those of the leg, and 
below the elbow motion seemed to be totally lost, while a little movement 
remained of the arm on the trunk. I think that during the two or three 
days succeeding the convulsions sensation in the right limbs was not en- 
tirely lost, though greatly enfeebled. Subsequently paralysis in the right 
limbs, both of the nerves of sensation and motion, was nearly or quite 
total, and continued so till death. Nevertheless, tickling the sole of the 
foot caused some movement of the great toe. On the left side sensation 
and motion were perfect. 

The record of December 9th runs : Has vomiting to-day for the first 
time; apparently sees well, and appearance of the eyes normal; has no 
retraction of head, or rigidity of muscles of neck, or along the spine ; 
pulse 96, temperature in the axilla normal ; lies quiet and with eyes shut; 
is stupid, but not particularly fretful, when aroused ; the bowels move 
regularly. 

December 11th, continues to vomit at intervals; pulse 68. Dec. 16th, 
pulse 80, temperature 100 ; vomited once yesterday, none to-day ; lies in a 
constant doze; takes bromide of potassium gr. iv three times daily. Dec. 
18th, moans at times, as if in pain ; pulse 180, temperature 100 ; takes the 
bromide gr. iv every four hours. 

Dec. 19th, pulse 180, temperature 103; there is convergent strabismus, 
and the eyes have a wild, almost insane, look, but she sees, grasping hur- 
riedly a percussion hammer presented towards her ; paralysis of nerves of 
motion and sensation in the right extremities nearly complete, slight move- 
ment still being produced in the great toe by titillation ; the vomiting has 
ceased; tongue covered with a thick fur; movements of the bowels pretty- 
regular; has a slight cough, such as is common in cerebral disease. 

Dec. 22d, lies quietly on her side in perpetual slumber, with eyes con- 
stantly shut; pulse 118, temperature 101} ; the bowels still move nearly 
normally ; the pupils, exposed to the light, are seen to oscillate, but are 



442 INFANTILE PARALYSIS. 

constantly more dilated than in health; the urine passes freely; has at 
intervals circumscribed flushing of the features; a rash like lichen over 
abdomen and chest, possibly due to the large quantity of bromide of po- 
tassium administered. 24th, pulse intermittent ; pupils dilated. 

Dec. 'ioth, died in profound stupor to-day, having lived nineteen days 
from the commencement of the malady. 

Autopsy. — About thirty hours after death ; weather cool. On I'emoving 
the calvarium and dura mater, which presented no unusual appearance, 
the vessels of the pia mater were found rather more injected than usual, 
but not more so than we sometimes observe in those, who die of diseases 
which do not involve the brain. The cerebro-spiual fluid was scanty, and 
the surface of the brain rather dry. The vertex of the left hemisphere 
was unusually prominent, rising perhaps half an inch higher than that on 
the opposite side. At the highest point, which was about one and a half 
inches from the median line, was a circular yellowish spot upon the surface 
of the brain about one and a half inches in diameter. Pressure upon 
this spot, made lightly, so as not to produce rupture, communicated the 
sensation of a large cavity underneath filled with liquid, and approaching 
to within two or three lines of the surface. There was no adhesion or 
exudation over this spot; and the surface of the brain appeared entirely 
normal, except a little cloudiness of the pia mater over a space which 
could be covered by a five-cent piece, a little posterior to the optic com- 
missure. The incised surface of the brain, at a distance from the abscess, 
showed no increase of vascularity. The right hemisphere appeared in 
every way normal, except that its lateral ventricle was filled with pus, but 
not distended. 

On the left side, occupying the centre of the hemisphere, was an abscess 
as large as the fist of a child of two years, extending from within two or 
three lines of the vertex, where its site corresponded with the yellow spot 
on the surface of the brain, to the roof of the lateral ventricle. Through 
this roof the abscess had burst, filling and distending the ventricle with 
pus, and thence making its way into the lateral ventricle of the opposite 
hemisphere. The whole amount of pus contained in the abscess and the 
two ventricles was, perhaps, two ounces. The walls of the left lateral 
ventricle Avere much softened, the upper part of the corpus striatum and 
thalamus opticus being nearly diflluent ; the walls of the right lateral 
ventricle were slightly softened, but to less depth. The parietes of the 
abscess, which extended from the roof of the ventricle to the vertex, as 
already stated, were indurated to the depth of one and a half lines in 
consequence of proliferation of the connective tissue, except at the base 
of the abscess, which corresponded with the roof of the ventricle, where 
softening had occurred. The spinal cord, so far as it could be examined 
from the cranial cavity, had the usual vascularity, and seemed nearly or 
quite normal. 

The cause of the encephalitis from which the abscess resulted was ob- 
scure. This inflammation, so far as can be ascertained, was idiopathic, 
which is known to be a rare disease. There was no history of otitis, which 
is one of the most frequent causes of cerebral abscess, nor of heart disease, 
so as to produce embolism. It seems probable, since there was no fever 
till about the fourth day after the convulsions, that an abscess had pri- 
marily occurred in the hemisphere between the roof of the ventricle and 
the vertex, possibly weeks previously. The bursting of this into the lateral 
ventricle, and the constitutional disturbance, inflammation, and softening 



SYMPTOMS. 443 

to which this would inevitably give rise, afford sufficient explanation of 
the history of the case, after the commencement of the convulsions. 

Paralysis occurring as a symptom, or sequel of some obvious local or 
general disease, as diphtheria, lesion of the nervous centres, etc., and 
which may occur at any age, need not detain us. It is described in con- 
nection with the primary diseases on which it depends. But there is a 
form of paralysis which in the present state of our knowledge we must 
consider an idiopathic malady, and which is peculiar to the first years of 
life, or is so rare at other periods that it is proper to regard it as strictly 
a malady of infancy and early childhood. It occurs between the ages of 
six months and three years. The following description relates to it. 

Symptoms. — The previous health of the patient is usually good. The 
paralysis does not always commence in the same manner. In a few 
instances it begins suddenly in the daytime when the child is apparently 
in perfect health. In some it begins abruptly, after sound sleep. The 
child goes to bed well, sleeps through the night, and awakens in the morn- 
ing paralyzed. I have known it to occur in one instance after sleep in the 
middle of the day. In these cases there has sometimes been an exposure, 
before the sleep, to wind or rain, or from sitting upon a cold stone. In 
other and the majority of cases the paralysis is preceded by a very decided 
febrile movement, which comes on suddenly, without appreciable cause, 
and after a few days the power of motion is found to be lost in one or 
more of the limbs. There is no symptom during the febrile movement 
to indicate any affection of the brain : consciousness is retained, and there 
is no more headache or apparent liability to convulsions than occurs 
in other pathological states accompanied by an equal amount of fever. 
Several other modes of commencement have been described by writers, 
but it is not improbable that they have embraced other forms of paralysis 
in their statistics, as for example those cases which are hemiplegic, or 
which occur in the course of a lingering disease, or a hsemorrhagic disease, 
or with cerebral symptoms, as vomiting. Such cases should not in my 
opinion be included in the statistics of infantile paralysis, since their 
nature is uncertain, nor indeed should any cases in which there is doubt 
as to their genuineness. In whatever way the paralysis begins, it is at its 
maximum in the commencement. Occurring as by a stroke, the full ex- 
tent of the paralytic state is exhibited at once, and so far as there is any 
subsequent change, it is an improvement, as regards the number of muscles 
affected, and the degree of the paralysis. Most frequently the paralysis 
affects one or both lower extremities. Occasionally one of the upper ex- 
tremities is also paralyzed in addition to the lower, but paralysis of an 
upper extremity is less in degree, and disappears sooner, than that of the 
lower. The bladder and lower bowels remain unaffected, since only the 
muscles of volition are involved. Sensation is unimpaired in the aftected 
limbs, and in the commencement there is even in some cases a state of 



444 INFANTILE PARALYSIS. 

hypera?sthesia (West). The febrile movement, which precedes and ac- 
companies the paralysis in certain cases, gradually abates, and in a few 
days nothing abnormal remains except the loss of power in the affected 
muscles. These muscles are in a flaccid and relaxed state, so that the 
limb falls by its weight when unsupported, and they are usually free from 
pain. The number of muscles paralyzed varies greatly in different cases. 
Only one muscle or a single group of muscles may be affected, or, on the 
other hand, both the extensor and flexor muscles of two or more limbs. 
In the opinion of Mr. Adams, the following table exhibits the groups of 
muscles and single muscles most frequently involved, and in the order 
stated. 

1. Extensors of toes, and flexors of the foot. 

2. Extensors and supinators of the hand. 

3. Extensors of leg, and Avith them usually the first group. 

Single Muscles. 

1. Extensor longus digitorum of toes. 

2. Tibialis anticus. 

3. Deltoid. 

4. Sterno-mastoid. 

The following is an example of infantile paralysis, as it not infrequently 
occurs when the result is favorable: A. K., German, female, aged 3 
years 4 months, fleshy ; had been in the habit of sitting on the ground 
near the house and on the door-sill. On July 2d, 1871, she had a sound 
sleep in the afternoon, having been entirely well previously, and awoke 
trembling and with a high fever at 3 J p. M. At 8 p. m., the febrile excite- 
ment continuing, general clonic convulsions occurred, lasting about ten 
minutes. At this time I w'as called to see her, and found the face flushed, 
surface hot, and pulse about one hundred and thirty. Consciousness re- 
turned after the convulsion. The intelligence was good, tongue moist and 
slightly furred, bowels rather constipated, and the urine was freely passed. 
The febrile excitement continued two days, when it gradually and entirely 
abated, but before it ceased paralysis of the left lower extremity was ob- 
served. No weight at first could be sustained upon this limb, and it hung 
powerless when we endeavored to make her walk. The attempt caused her 
to cry, as if in pain, and pressing upon the thigh, or moving it, had the 
same effect. The thigh of this limb did appear slightly swollen on inspec- 
tion, but measurement did not indicate any notable enlargement. The 
difference in circumference was certainly not more than one-eighth to one- 
fourth of an inch. There was no appreciable increase of heat in the thigh 
over the general temperature of the body. Sensibility remained in every 
part of the limb, and the loss of power was not complete, for on the first 
day, as soon as the paralysis was observed, slight and imjierfect movements 



PKOGNOSIS — PROG E ESS ETIOLOGY. 445 

could be pi'oduced by pinching the limb. In three weeks the use of the 
limb was fully restored, by mildly stimulating liniments, and simple medi- 
cines to regulate the bowels. The tenderness, which was observed in this 
case, is only occasionally present. It has been attributed to hypersesthesia, 
but those who hold to the peripheral origin of the paralysis, would probably 
attribute it to the anatomical change occurring in the terminal nerve-fibres. 

Prognosis — Progress. — The paralysis in nearly all cases soon begins 
to abate. The power of motion returns little by little, and whatever im- 
provement occurs is permanent. There is no retrogression in the convales- 
cence. The sooner improvement commences, the more favorable is the 
prognosis. In the most favorable cases there is complete restoration in from 
three to four weeks. In other patients, while certain of the muscles i-egain 
the power of motion, other muscles, oftener those of the lower extremity 
than upper, do not recover their function, and, unless proper remedial 
measures are employed, and even with them in certain instances, atrophy 
soon commences. The temperature of the paralyzed limb falls three, five, 
or even eight degrees, and the amount of blood which circulates in it is 
diminished so that the pulse of the limb is feebler and its vessels smaller 
than in health. With the atrophy the contractility of the muscular fibres 
by the electric current diminishes, and in unfavorable cases after a time 
powerful induced and even primary currents have no appreciable effect. 
The nutrition of a paralyzed limb is always imperfect, and if the paralysis 
occur in a child, its growth is retarded. Therefore in cases of protracted 
or permanent infantile paralysis of one limb a disproportion occurs both in 
diameter and length between it and that on the opposite side. If the 
paralysis continue, the ligaments of the paralyzed limb become relaxed and 
lengthened. West mentions a case of paralysis of the deltoid in which the 
humero-scapular ligaments were so extended that the humerus dropped 
from the glenoid cavity, so as to increase the length of the limb three-fourths 
of an inch. In the paralysis of certain muscles of the lower extremity, and 
continuance of the contractile power in others, we have the conditions which 
give rise to club-feet, and accordingly this deformity is the common result 
of the paralysis when it is not cured. 

Etiology. — As infantile paralysis is not a fatal malady, opportunity 
for a post-mortem examination in a recent case seldom occurs. Hence 
the difficulty in determining the exact anatomical change in the nervous 
system which produces the paralysis. There are now in medical literature 
records of a considerable number of cases in which autopsies have been 
made, but death occurred so long after the commencement of the pa- 
ralysis, usually months or years, that it is difficult to determine whether 
lesions which have been observed were a cause or consequence. In a 
majority of these autopsies a spinal lesion of some sort was detected, but 
none could be discovered in u few instances, the most important of which 
were the following : 



446 INFANTILE PARALYSIS. 

Mr. Adams, in his treatise on club-foot, relates a case in which the spinal 
cord, carefully examined, probably only with the naked eye, seemed 
normal. Robin examined the spinal cord microscopically in one case, but 
discovered nothing abnormal, and Elischer made two .autopsies in cases of 
this paralysis which had succumbed to variola, but with a negative result 
as regards any lesion in the nervous system (Jahrbuch. fur Kinderk., 1873). 
The examinations by Robin and Elischer, since they were microscopic, 
have been justly regarded as important, and they have been related by 
certain writers in order to sustain the theory that infantile paralysis is 
peripheral, and not centric. But may there not have been a spinal lesion 
which caused the paralysis, and abated, leaving no trace, although its 
effects as regards the muscles continued ? 

Very little was effected, prior to 1863, in determining the cause or 
causes of infantile paralysis by post-mortem examinations, because the 
microscope was so little used, and because in most of the cases reported 
the clinical history or microscopic lesions were such as to show or to render 
it highly probable that the paralysis was not such as is designated and 
understood by the term infantile. Thus Beraud reported a case in which 
tubercles were found in the spinal cord. Hutin, a case in which there 
was atrophy of the lower part of the spinal cord, but the paralysis com- 
menced at the age of seven years. Hammond, a case in which a clot was 
found in the spinal cord ; and Jaccoud, one of spinal arachnitis, with thick- 
ening of the meninges. Since 1863, seventeen autopsies have been re- 
corded in which the spinal cord was carefully examined, and upon these 
we must chiefly rely for our data by which to determine what are the ana- 
tomical changes in the nervous system which probably cause this paralysis. 
The reader will find these cases tabulated in a lecture by E. C Seguin, 
M.D., published in the N. Y. Med. Record, January loth, 1874, and the 
most important of them narrated in a paper on infantile paralysis, showing 
great research, published by Dr. Mary Putnam Jacobi, in the N. Y. Obst. 
Jour, for May, 1874. It is true that all but three of these post-mortem 
examinations were made many years after the occurrence of the paralysis; 
but in the three cases which were reported by Roger and Damaschino, 
only two, six, and thirteen months had elapsed. The following were the 
chief lesions observed in these cases as regards the spinal cord : 

Cases. 

1. Atrophy of motor-colls in anterior cornua, ....... 10 

2. Ncr%'e-cells, normal, 2 

3. Atrophy (variously recorded) of anterior columns, or cornua, or part of 

cord, or roots of anterior nerves, 8 

4. Sclerosis, 9 

5. Mj'elitis, recorded as diffused, central, or slight, ...... 7 

6. Central softening (the three most recent cases), ...... 3 

7. Small clot in cord (Hammond's case), ........ 1 

8. Sciatic neuritis, . . ......... 1 



ETIOLOGY. 447 

It is seen that the most common lesions in these cases were those of 
inflammation of the spinal cord, or such as are known to result from this 
inflammation, to wit, atrophy of the nervous substance and sclerosis. 

With the data furnished by these post-mortem examinations and the 
clinical histories of cases we are the better prepared to consider the theories 
regarding the etiology of this malady. The views of MM. Roger and 
Damaschino are entitled to great consideration, since the autopsies which 
they made were in cases of shorter duration, and therefore nearer the date 
of the commencement of the paralysis than those which have been reported 
by other observers. Roger and Damaschino published a series of papers 
on this malady in the Gaz. Med. de Paris in 1871, which they conclude 
with the following propositions : " 1. The alteration peculiar to infantile 
paralysis is a lesion of the spinal marrow, which causes the atrophy of 
muscles and nerves. 2. The seat of this lesion is the anterior part of the 
gray substance of the medulla, where softened portions of spinal substance 
are seen. 3. This softening is of an inflammatory nature — in fact, a 
simple myelitis. 4. Infantile paralysis should, therefore, be called spinal 
paralysis of children, and be classed among the affections of the spinal 
marrow, as depending on myelitis." 

To determine the exact character and limitations of the cause of infantile 
paralysis is difficult, but the views of Roger and Damaschino, as expressed 
in the above propositions, seem to harmonize more closely with, and to 
afford a more satisfactory explanation of the symptoms, history, and lesions, 
thus far observed in ordinary or typical cases, than does any other theory. 
Suddenly occurring, active congestion of the anterior cornua, many neur- 
opathists regard as the cause of infantile paralysis ; but there is that close 
aflSuity between active congestion and inflammation that they may be 
regarded as having the same pathological effect in this instance, and there- 
fore the two theories of a spinal congestion and spinal inflammation may 
be considered as one. It is not improbable that in some of the cases which 
more speedily recover there is simple congestion ; while in the more obsti- 
nate cases, and those with inflammatory symptoms, the congestion has 
passed iuto an inflammation, or inflammation was present from the first. 
According to this theory the atrojihy so generally observed in the twelve 
cases in which autopsies were made, must be considered a degenerative 
change resulting from the inflammation or from the paralysis. That so 
accurate an observer and so excellent a microscopist as Robin could detect 
nothing abnormal in the case which he examined, was probably due to 
the fact that the inflammation or congestion abated without producing any 
degenerative changes in the nervous substance. 

Professor Charcot considers atrophy of the motor cells as the cause of 
the paralysis, but it is much more in consonance with the facts to con- 
sider the cellular atrophy a result than a cause. For how could atrophy, 
which always occurs gradually, and by progressive increase, be the cause 



448 INFANTILE PARALYSIS. 

of a disease which begins abruptly, and is most intense in the very com- 
mencerxieut ? Besides, atrophy does not occur without some antecedent 
disease to cause it. 

It would be a waste of time to consider in full the various theories re- 
garding the cause of infantile paralysis. No one at the present time of 
those who are competent to express an opinion, believes it to be a reflex 
pai'alysis, and the expression dental paralysis once applied to it is no longer 
heard. There is one theory, however, which should receive more than a 
passing notice, and which was earnestly and ably advocated by Barwell, 
of Loudon, iu lectures published by him in 1872, in the Loudon Lancet, to 
wit : " That this paralysis is purely peripheral ; a malady affecting the 
ultimate fibrillse of distribution of the nerves among the muscular ele- 
ments. . . . Its essence," says he, "lies probably in some subtile derange- 
ment in relationship between the ultimate muscular and terminal nerve- 
fibres, perhaps from some inflammatory, perhaps from some chemical or 
nutrient change." This theory has much to commend it. Those who ad- 
vocate it believe that the atrophy of the nerves which supply the para- 
lyzed limbs and of the motor nerve-cells which connect with the roots of 
these nerves in the anterior cornua occurs in consequence of the paralysis, 
just as atrophy of the optic nerve can be traced even into the brain when 
the eye is destroyed. Nor does it dispose of this theory to state, as has 
been stated, that in order that paralysis occur in this manner, it is neces- 
sary that there should be the action of a poison, analogous to the woorari, 
for we observe something similar to this supposed peripheral cause in facial 
paralysis from exposure to cold, in which there can be no poisonous in- 
fluence. This theory therefore rises up most strongly in conflict with that 
which attributes the paralysis to a congestion or inflammation of the an- 
terior cornua, and it is necessary to decide between them, or to admit that 
the paralysis may sometimes have one and sometimes the other cause. 
But the fact that there is in many cases of infantile paralysis a decided 
febrile movement, and much constitutional disturbance, when there is no 
evidence of any morbid action going forward in the affected limbs suffi- 
cient to cause these symptoms, and the fact that only one set of nerves is 
aflTected, namely, the motor, which have a distinct origin in the spine from 
the sensitive nerves, but are intimately associated with them in their dis- 
tribution, comport best with the theory of a central lesion. Therefore, the 
theory of spinal congestion or inflammation appears the best established. 
Nevertheless, all past experience shows that medical theorizers are apt to 
be too exclusive, and that in many diseases there is not a simple uniform 
cause, but that the cause may vary, especially when, as in the present 
instance, the symptoms also vary ; possibly, therefore, we may yet find that 
there are cases, especially those in which there is little constitutional dis- 
turbance and a known exposure to cold, in which the cause is peripheral 
instead of centric. The brain and cerebral meninges may be excluded as 



ANATOMICAL CHARACTERS PROGNOSIS. 449 

sustaming any causative relation to the paralysis. There is no symptom 
which indicates that they are involved. The mind remains clear, and con- 
vulsions are no more frequent than in any other disease which is attended 
by an equal degree of febrile reaction. 

Anatomical Characters. — All muscular fibres which are in a state 
of disuse, begin in a few weeks to atrophy, and undergo &tty degenera- 
tion. The transverse striae in the primitive muscular fasciculus gi'adually 
disappear and are replaced by granules of fat, and later still by small oil- 
globules. If we examine with the microscope the fibres from a muscle 
which has been a considerable time paralyzed, but which has still some 
electric contractility, we will find in places the strige remaining, but numer- 
ous opaque granules of a fatty nature within the sarcolemma wherever the 
striae are absent, and in other places, where the degeneration is most ad- 
vanced, oil-globules occur, always small. If the paralysis is more pro- 
found, the striae have all disappeared. At a later stage, usually after some 
years in cases of complete and incurable paralysis, the fatty matter may 
be to a considerable extent absorbed, and the fibrous network of the muscle 
which remains presents a tendinous appearance. There is a great dif- 
ference, however, in different cases, as regards the rapidity with which 
these changes occur. Hammond states that he found the striae remaining 
in two cases after the lapse of more than four years of decided paralysis. 
The nerves of the paralyzed part also undergo atrophy. 

Diagnosis. — This is easy as soon as the attention of the physician is 
directed to the state of the limbs. In a large proportion of cases the 
mother or nurse first observes 'the paralysis, and calls the attention of the 
physician to it. A knowledge and recollection of the facts in relation to 
infantile paralysis should lead the physician to examine the state of the 
limbs in all cases of great febrile excitement in young children, occurring 
without apparent cause. 

Prognosis. — It may be confidently predicted, if the child is seen early, 
and correctly treated, that the paralysis will diminish, if it cannot be en- 
tirely cured. If the paralysis has continued a considerable time, and there 
is no electric contractility of the muscles, there is poor prospect of any im- 
provement. The induced current will fail, sometimes, to cause muscular 
contraction, when the direct current may produce it ; but if there is no 
response to the direct current, there is no therapeutic agent which can re- 
store the use of the limb. 

In cases seen soon after the paralysis commences, and before the stage 
of atrophy, the prognosis is most favorable, when there is still slight vol- 
untary motion, and improvement commences early. In most instances, 
even when the paralysis has been mild, and of comparatively short dura- 
tion, the limb, although its motion is fully restored, is for a long time 
weaker than the limb on the opposite side. 

Treatment. — A physician called at the commencement of the jsa- 

29 



450 INFANTILE PARALYSIS. 

ralysis should endeavor to remove every cause which might increase the 
irritability of the nervous system. It is proper to scarify the gums, if much 
swollen and tender from dentition, the bowels should be kept regular, 
worms, if present, expelled by appropriate medicines, and the diet be plain 
and unirritating. As the cause of the paralysis is in the commencement 
still operative, measures are appropriate which are calculated to remove it. 
Local treatment is very important at all periods of the paralysis. In 
the first days a tepid hip-bath employed daily, with brisk friction of the 
surface, has a salutary eflect. Stimulating embrocations along the spine, 
and upon the paralyzed limb, are appropriate also at an early date. Pos- 
sibly, if there is a strong probability of spinal congestion, cold applied 
along the spine, by ether spray or otherwise, might be useful, but I am 
not aware that it has been employed in this disease. If the paralysis ap- 
pear to have a central origin, ergot, the bromide and iodide of potassium, 
which may be administered variously combined, or singly, are the appro- 
priate remedies for the first twelve or fourteen days. Administered every 
three or four hours in proper dose, they are the most efiectual of all inter- 
nal remedies for diminishing spinal congestion, and preventing effusion, 
and permanent structural change in the cord. 

If the paralysis continue, or is not progressively diminishing, we should 
not delay more than two weeks from the commencement of the disease be- 
fore employing appropriate measures to restore the use of the limbs, and 
prevent atrophy of the muscles. The expectant plan of treatment which 
is proper in many diseases of children is unsuited to this. Muscular 
atrophy may commence in three weeks, and the further it has advanced, 
the more difficult and tedious will be the cure. Therefore, by the close 
of the second week if the paralysis continue, or is not rapidly disappear- 
ing, iron as a tonic with strychnia should be prescribed. There is prob- 
ably no better formula for the exhibition of these agents than the follow- 
ing from Professor Hammond : 

R. Strych. sulphat., gr., j. 

Ferri pyrophosphat., ^ss. 

Acidi phosphorici dilut., ^ss. 

Syr. zingib.,, §iijss. Misce. 

One-third of a teaspoonful, or one-ninetieth of a grain of strychnia, is 
sufficient for a child of two years, administered three times daily. Hillier, 
Barwell, and others have employed subcutaneous injections of strychnia, 
with, it is stated, a good result. While in the first and second weeks the 
child has been allowed to remain quiet, he should now be encouraged to 
use his limbs. Frequent muscular contraction must, if possible, be pro- 
duced, and the voluntary movements, when not totally lost, aid greatly in 
promoting the nutrition of the muscles and restoring their function. Im- 
mersing the limb for half an hour in water at a temperature of 110 or 115 
degrees, rubbing the limb with a coarse towel, and kneading the muscles, 
aid also in restoring nutrition and tone to them. 



FACIAL PARALYSIS. 451 

But, fortunately, we have an invaluable agent in the subtle electrical 
fluid, which can be made to penetrate the muscles and cause their contrac- 
tion when every other measure has failed. The induced current should be 
employed upon the limb every day, or second day, if it cause the muscles 
to act, but if the loss of power is of long standing, or complete, so that the 
induced current is not sufficiently powerful, the direct current should be 
used instead. It is not regarded as important which way the current 
passes, provided the muscles contract. 

In a large proportion of cases a cure cannot be effected until the lapse 
of several months, so that the patience of the physician and friends may 
be put to the test ; but if muscular atrophy can be prevented, and the 
limb kept at near the normal temperature, this mode of treatment will 
ordinarily in the end be successful. The primary affection which caused 
the paralysis will, with some exceptions, abate of itself, so that the state 
of the muscles and their nervous supply demand the whole attention. Ob- 
servations show that by treatment perseveringly employed, fatty degen- 
eration of the muscular fibres can be not only arrested, but the fat which 
has already been deposited within the sarcolemma may be absorbed, and 
the muscular strise restored. In those cases in which it has been necessary 
to employ the direct current, the induced should be employed, whenever 
by the improvement of the case it is found sufficiently powerful. 



CHAPTER XVI. 

FACIAL PAKALYSIS. 

Causes. — Facial paralysis, in the newborn, commonly occurs from 
pressure of the blade of the forceps upon the portio dura, at a point ex- 
ternal to the stylo-mastoid foramen. It may also occur in children of 
any age, as it is known to be in the adult, from exposure of the face to a 
cold wind. The pressure of a tumor upon some part of the portio dura, 
or even of the fist of the child placed under the face during sleep, may 
cause it. It may also result from disease of the temporal bone, producing 
pressure on the nerve, as caries, periostitis, suppuration, or haemorrhage 
into the aquseductus Fallopii, and also from intracranial disease affecting 
the pons Varolii or the medulla oblongata. 

Symptoms. — The portio dura, which is a nerve of motion, supplies the 
muscles of the face, and therefore its loss of function is at once manifest in 
distortion of the features. The eye of the affected side remains open in 
consequence of paralysis of the orbicularis palpebrarum, the upper lid 
being raised by the levator muscle, which is not paralyzed, as its nerve is 
derived from the third pair. From the inability to wink, the eye becomes 
irritated by dust and constant exposure, and, in children old enough to 



452 PARALYSIS WITH PSEUDO-HYPERTROPHY. 

have an abundant lachryraal secretion, the tears are apt to flow over the 
cheek. On account of the paralyzed and relaxed state of the facial muscles 
the mouth is drawn towards the healthy side, while the affected side pre- 
sents a swollen appearance. Movement of the eyebrow and of the anterior 
portion of the scalp on the paralyzed side is also impossible, since the 
occipito-frontalis and corrugator supercilii are supplied by the portio dura. 
If the cause of the disease is located above the origin of the chorda tym- 
pani, the flow of saliva, and consequently the taste, on the affected side 
are impaired. If the injury is posterior to the gangliform enlargement, 
those symptoms are superadded which are due to paralysis of the petrosal 
nerves. 

Prognosis. — This depends on the cause. If the cause is peripheral, as 
from the pressure of the forceps or from cold, the prognosis is favorable. 
In cases of deep-seated lesion, unless syphilitic, the prognosis is usually 
unfavorable. A syphilitic lesion can often be removed by appropriate 
remedies and the paralysis cured. 

Treatment. — In the paralysis of the new-born, from pressure of the 
forceps, all that is required is occasional rubbing or gentle kneading over 
the affected muscles. In those who are older, the nature of the cause, so 
far as ascertained, must determine the treatment. If there are glandular 
swellings, and discharge from the ear from scrofula, cod-liver oil and the 
syrup of the iodide of iron are required internally, with appropriate ex- 
ternal treatment of the glands and ear. If syphilis is the cause, mercurials 
and the iodide of potassium should be employed. If the patient do not 
soon begin to improve, the treatment recommended for infantile paralysis, 
modified somewhat on account of the difference in location, is appropriate. 
Iron and strychnia may be administered internally ; friction, kneading, 
hot applications, and the electric current employed. The current should 
have only moderate intensity, for a high degree of it might injure the vision. 
It should be applied every second day, with one pole over the mastoid 
foramen, and the other moved slowly over the muscles. 

Paralysis -with Pseudo-Hypertrophy. 

This is a rare disease. It was first described by Duchenne in 1861, and 
since the attention of the profession was directed to it, cases have been ob- 
served on the Continent, in Great Britain, and in this country. Though 
our acquaintance with this disease is so recent, it has been fully and accu- 
rately described by various writers in our language. The Transactions of 
the Lond. Path. Soc. for 1868 contain a translated paper relating to this pa- 
ralysis, communicated by M. Duchenne, with photographic views, remarks 
by Lockhart Clarke, and also the histories of two cases occurring in Lon- 
don, and exhibited to the Society by Adams and Hillier. In this country 
an elaborate paper has appeared on this form of paralysis, from the pen of 
Dr. Webber, of Boston, who succeeded in collecting the records of forty-one 



PARALYSIS WITH PSEUDO-HYPERTROPHY. 



453 



cases. (Bost. Med. and Surg. Jour., Nov. 17th, 1870.) And more recently 
Dr. Poore, physician to the New York Charity Hospital, collated the records 
of eighty -five cases, which furnish the material of an excellent monograph 
published in the Neiv York Medical Journal for June, 1875. 

Weakness of the legs, aad a peculiar waddling gait, are the first ob- 
servable symptoms, and by them we are able to ascertain approximately 
the date of the commencement of the paralysis. In 27 of the cases col- 
lated by Dr. Poore, the malady began so early in infancy that they were 
never able to walk like other children ; in 5 there is no record in regard to 
the time when the peculiar gait was first observed, or whether they ever 
could walk. Fifty-two, or about two-thirds of the cases, walked well at 
first, having no symptoms of the paralysis till after the age of two years. 
In 15 of these weakness of the legs and the peculiar gait were fii-st ob- 
served between the ages of two and a half and five years ; in 23 between 
the ages of five and ten years ; in 6 between the ages of ten and sixteen 
years, and in 8 over the age of sixteen years. It is seen, therefore, that this 
malady is pre-eminently one of infancy and childhood. 

The gait, which is unsteady and waddling, has been compared to that of 
a duck. The child stands with the legs wide apart, and from the weakness 
of the legs, and unsteadiness of the gait, frequently stumbles and falls. In 
many cases this muscular weakness and difiiculty in walking occur before 
there is any perceptible enlargement of the muscles beyond the noi-mal size. 

The hypertrophy occurs without tenderness, pain, or other nervous symp- 
toms, and without fever or constitutional disturbance. Occasionally the 
patient complains of stiffness or aching in the limbs, especially after exer- 
cise, even before the enlargement is observed, and exceptionally there is 
pain, even acute, in the legs. The hypertrophy 
is ordinarily observed first in the calf of one leg, 
and then in the opposite calf In a case related 
by Niemeyer, the muscles of the gluteal region 
were first affected. In nearly all cases the gas- 
trocnemii arehypertrophied. There were only 
two exceptions in the 85 cases collated by Dr. 
Poore ; but almost any of the other muscles, or 
groups of muscles, may also be involved. The 
muscles which are most conspicuously affected, 
and which produce the characteristic deformi- 
ties, are those of the extremities and posterior 
aspect of the trunk. Spinal curvature, which is 
attributed to the weakened state of the erector 
muscles of the spine, appears early, and is 
seldom absent. The bending is such that a 
plumb-line, falling from the most posterior of 
the spinous processes, falls behind the plane of 
the sacrum, which is a means of distinguishing this disease from certain 




454 PARALYSIS WITH PSEUDO-HYPERTROPHY. 

other spinal affections. The first woodcut represents a case which came to 
the children's class at Bellevue, in April, 1872. The boy was 2 years old, 
and the mother stated that the peculiar gait and the enlargements had only 
been observed from four to six weeks, and yet the curvature of the spine 
was quite marked. He did not return to the class, and his subsequent 
history is therefore unknown. 

Of the muscles in the upper extremities the deltoid and scapular are 
the most frequently enlarged. Hypertrophy of the temporals has been 
observed in three cases, of the raasseters in two, of the tongue in three, 
and of the heart in four (Poore). 

We shall see presently that atrophy occurs in the muscular element of 
the muscles which are affected, and that the hypertrophy is due to hyper- 
plasia of the connective tissue. Now occasionally this hyperplasia does 
not occur or is tardy in occurring, while the atrophy has taken place. 
Therefore certain muscles may have less than the normal volume, which, 
from contrast with those which are hypertrophied, increases the deformed 
appearance. In ordinary cases the enlargement advances more rapidly 
and continues greater in the gastrocnemii, which are, as we have stated, 
the muscles first affected, than in other muscles, and therefore there is 
more prominence and hardness of the calves of the legs than elsewhere. 
In advanced cases walking is impossible, and the patient is obliged to re- 
main iu a reclining posture. Sometimes from the unequal muscular action 
the feet become extended and the toes flexed, so that the child in attempt- 
ing to walk steps on the anterior part of the sole of the foot, as in talipes 
equinus. 

In the first stages of the disease the electric contractility of the muscles 
is nearly normal, but in advanced cases response to the galvanic current 
becomes more and more feeble, according to the degree of atrophy of the 
muscular fibres. The skin retains its normal sensibility, with exceptional 
instances in which there is numbness either general or in places. Reddish 
or bluish mottling of the surface of the extremities is sometimes observed, 
which is attributed by some to obstructed venous circulation in the hyper- 
trophied muscles, and by others is supposed to be due to the peculiar 
neuropathic state. The bladder and rectum are not involved. The 
mental faculties are more or less blunted and feeble in certain cases, 
especially in those which commence in early infancy, but in some patients 
they do not seem to be materially impaired. 

Anatomical Characters. — There have been so few post-mortem ex- 
aminations of those who died having this disease, that it is still uncertain 
whether there is any centric lesion. Cohnheim examined the spinal cord 
in one case, and could find nothing abnormal. Recently, Mr. Kesteven 
has examined the brain and spinal cord from a case, and found dilatation 
of the perivascular canals, both in the brain and spinal cord, and also 
spots of granular degeneration chiefly in the white substance, " caused by 



CAUSES. 455 

loss of cerebral tissue replaced by morbid matter." {Jour, of Mental Sd., 
Jan. 1871.) As this child was imbecile, it is not improbable that these 
lesions were connected with the mental state, and not the muscular disease. 

Professor Charcot (Archiv. de Physiol, March, 1872) reports a careful 
microscopic examination of the spinal cord and of the nerves in a case 
which had continued ten years. He could discover no deviation from the 
healthy state. More recently Dr. J. Lockhart Clarke examined a case 
and found the eucephalou healthy, but in the spinal cord there was more 
or less disintegration of the gray substance in each lateral half, and in 
places dilatation of vessels, and commencing sclerosis {Medico- Cliir. Trans., 
1874). 

It seems, therefore, that central lesions are not essential, and are some- 
times absent. When they do occur, it is probable that they are consecu- 
tive to the paralysis. 

The essential lesions in this malady are atrophy of muscular fibres and 
hyperplasia of the connective tissue which surrounds these fibres. The 
hyperplasia of the one element in the muscle is greater than the atrophy 
of the other, and hence the increase of volume above the normal size. 
The atrophy is probably a primary lesion, for muscular weakness ordi- 
narily occurs for a considerable time before there is any evidence of the 
enlargement, and, as we have seen, certain muscles may undergo the 
atrophy without the hyperplasia. Still the mechanical effect of the 
newly-formed connective tissue, doubtless, increases the atrophy in those 
muscular fibres which this tissue surrounds, and the comparatively quiet 
state of muscles in consequence of paralysis not only tends to promote the 
atrophy and degeneration of these muscles, but also of contiguous healthy 
muscles. 

The muscles which are involved in this paralysis present a pale yellow- 
ish hue, resembling, says Niemeyer, the appearance of lipoma. Examin- 
ing by the microscope, we find in addition to a large increase in the 
fibrous tissue, and atrophy and in some places disappearance of the mus- 
cular element, more or less fatty matter, granular and globular, occupy- 
ing the interstices. Mr. Kesteven describes as follows the appearance of 
the muscles in the case which he examined : " The muscular substance is 
pale, almost white, and very greasy. The superabundance of fat is evi- 
dent to the naked eye. The muscular fibres present the ordinary striation, 
but less distinctly than usual. The ultimate fibres are pale, and separated 
by a large increase of areolar and fibrous tissue." 

Causes. — Why there is this strange perversion of nutrition, so that 
there is an exaggerated development of the intermuscular connective 
tissue, and atrophy of the muscular fibres, is unknown. Boys are more 
apt to be affected than girls. Of the eighty-five cases embraced in the 
statistics of Dr. Poore seventy-three were boys, and there was a similar 
excess of males in the cases collated by Dr. Webber. 

There is in a considerable proportion of cases the record of hereditary 



456 DISEASES OF THE SPINAL CORD 

transmission, and in almost all the instances the predisposition is acquired 
from the mother's side. Thus in thirty-seven of Dr. Poore's cases " two 
or more belonged to the same family." In some instances three and even 
four maternal relatives had this form of paralysis. In one case observed 
by Duchenne, and in a few others subsequently observed, this malady 
seemed to be congenital, for the limbs at birth were unusually large, and 
the patients, when they came under observation, were unable to walk. 
No relation has been observed between this paralysis and syphilis, scrofula, 
or other diathetic diseases.] 

Prognosis, — This disease is in most instances progressive, terminating 
fatally after a variable period. It is in its nature chronic, rarely ending 
in less than five or six years, and a considerable proportion living longer, 
some even attaining adult age. The paralysis may be stationary for a 
time, but afterwards continue to increase. Duchenne has reported one 
case of recovery. In two or three other instances patients appeared to 
improve somewhat under treatment, but the writers admit they may have 
become worse afterwards. Death is apt to occur, not directly from the 
paralysis, but from some intercurrent disease, especially of the lungs. 

Treatment. — The treatment thus far employed has been chiefly local, 
consisting in the use of electricity, and kneading or shampooing over the 
aflfected muscles. Both the primary and induced electrical currents have 
been employed, but, unfortunately, without any appreciable benefit in 
most cases. Benedikt, who claims a better result from electrization than 
any other observer, applied the copper pole over the lower cervical gau- 
gliou, and the zinc pole along the side of the lumbar vertebrte by means 
of a broad metallic plate. 



CHAPTER XVII. 

DISEASES OF THE SPINAL CORD AND ITS COVERINGS. 

The diseases of the spinal cord, and of the parts which cover and pro- 
tect it, are important, but they are less understood than are those of any 
other part of the body. This is partly due to the fact, that in many cases 
the spinal disease coexists with a similar pathological state of the brain 
or its meninges, the symptoms of which predominate and mask those which 
pertain to the spine, partly to the fact that the chief symptoms of spinal 
disease are often located in organs or parts which are at a distance from 
the spine, and lastly, to the fact that it is difficult, for obvious physical 
reasons, to determine the exact state of the spine at the bedside ; while 
post-mortem inspection of the spine, which alone can give accurate patho- 
logical knowledge, is less frequently made than of any other organ. 

Certain spinal diseases occurring in childhood are the same as in adult 



AND ITS MEMBRANES. 457 

life, presentiug identical symptoms and lesions in the two periods, and 
therefore they require no extended notice in this treatise. Others are 
common to childhood and maturity, but they present peculiarities in the 
former period, which require to be pointed out, while others still are 
peculiar to childhood. 

Spinal irritation is not infrequent in delicate and poorly-fed children. 
I have from time to time observed marked cases of it in the class in the 
Outdoor Department of Bellevue, the patients usually being above the 
age of three or four years, and exhibiting evidences of cachexia. Most 
of them have been spare and pallid, some affected with a nervous cough or 
palpitation, and some with neuralgic pains in the chest, abdomen, or else- 
where, which pressure at a certain point upon the spine intensified. These 
cases recover by better feeding, outdoor exercise, mild counter-irritation 
along the spine, and the use of tonics, especially of iron. 

Primary inflammation of the cord and its meninges is rare in children. 
Secondary inflammation of these parts is, on the other hand, more common 
in children than in adults. It is common in caries of the vertebrse, and 
in cerebro-spinal fever. The preponderance in functional activity of the 
spinal cord, and the feeble controlling power of the brain, render child- 
hood more liable to convulsions and reflex paralysis than any other period 
of life. Until within a recent period, most cases of infantile paralysis were 
believed to be reflex, due to dentition, intestinal irritation, etc., but it is now 
attributed to congestion of the spine, or to disease of the nervous filaments 
at the seat of the paralysis. Still there are cases of true reflex paralysis 
in children, in regard to the etiology of which there can be no doubt. 
Prof. Sayre of this city has called attention to the fact, that balanitis and 
prseputial adhesions sometimes cause paraplegia, more or less pronounced, 
in young children, and which is relieved by dividing the adhesions, and 
restoring the mucous surface of the glans and prepuce to its normal state. 
Such a case was brought to the children's class in the Outdoor Department 
at Bellevue, in April, 1 875. The child could not walk, or scarcely stand, 
without support, but after the division of the adhesions, and subsidence of 
the inflammation, locomotion rapidly im2:)roved.^ It is well known that 
masturbation sometimes causes a similar weakness of the lower extremities. 
Dr. West relates the case of a child " between two and three years old," 
who began to totter in his gait, and finally almost ceased walking. He 
was observed to practice masturbation. " This was put a stop to," and 
he soon recovered his health and his power of locomotion. {Diseases of 
Children, page 146, 4th American edition.) . > 

1 Some months since I requested Drs. Holgate and Bosly, attending physicians 
in the children class at Bellevue, to make examinations of the state of the prepuce 
in infancy. They report that they have found preputial adhesions almost daily, in 
most instances without symptoms, but sometimes with dysuria, and only in rare 
instances with paralysis. 



458 CONGESTION OF SPINAL CORD, ETC. 



Congestion of the Spinal Cord and its Membranes. 

Congestion of the spinal cord and meninges occurs both as a primary 
and secondary malady, the latter being more frequent than the former. 
It may be active or passive. Active congestion, occurring independently 
of meningitis or myelitis, is in most instances transient, and subordinate to 
some graver disease, in the course of which it arises. It is probably often 
overlooked. It is not fatal, and its symptoms are often masked by those 
which are referable to the brain or some other organ. It is believed to be 
common in the initial period of certain of the fevers of childhood. It is 
not improbable that the hyperesthesia observed upon the thoracic and ab- 
dominal surfaces and along the thighs, in the commencement of remittent 
and certain other febrile diseases, have their origin in a congested state of 
the spine. To this congestion writers attribute the lumbar pain and oc- 
casional paraplegia in the initial stage of variola. Active spinal con- 
gestion may also result from the sudden impression of cold, and to it, as 
we have stated elsewhere, most neuropathists attribute those sudden at- 
tacks of paralysis which are peculiar to infants, and which have therefore 
been designated infantile paralysis. 

Certain anatomical circumstances favor the occurrence of passive con- 
gestion of the spinal cord and meninges, to wit, the tortuousness of their 
veins, and the absence of valves in these veins, the lack of muscular sup- 
port of the vessels, and the inferior position of the spine in sickness as the 
patient lies quietly in bed. A common cause of passive congestion of these 
parts is some protracted and enfeebling disease, which diminishes the con- 
tractile force of the heart (cardiac paresis), producing congestion of the 
spinal cord in the same manner as under similar circumstances hypostatic 
congestion of the lungs occurs. Severe convulsive diseases, as tetanus or 
eclampsia, when protracted or occurring at short intervals, commonly 
produce spinal congestion. In tetanus, this congestion is extreme, so that 
extravasation of blood is apt to occur from the engorged vessels, especially 
from those of the pia mater. 

Anatomical Characters. — It is often impossible, at post-mortem ex- 
aminations, to determine how much of the congestion of the spine and its 
meninges is pathological, and how much cadaveric ; since, if the corpse is 
placed on its back at death, a very considerable engorgement of the spinal 
vessels occurs from gravitation of blood. If the body has been placed on 
the side or face, this cadaveric congestion is prevented. Since, in active 
congestion, the arterioles and capillaries are distended with arterial blood, 
the color is a brighter red than in passive congestion, in which venous 
blood predominates. Active congestion of the cord usually coexists with 
that of the meninges, but it may occur without it. In cases of consider- 
able congestion, the "puncta vasculosa" appear upon the incised surface, 
both of the white and gray substance. If the congestion be protracted, or 



SYMPTOMS — TREATMENT. 459 

if it recur frequently, it may produce permanent dilatation of the arterioles 
and capillaries, in greater or less degree, and it may also lead to sclerosis 
of the cord. Passive congestion seldom, perhaps never, occurs in the cord, 
without being equally and often to a greater extent present in the menin- 
ges. Continuing for a time it gives rise to transudation of serum into the 
interspaces over the cord, and even softening of the cord may occur to a 
limited extent from imbibition of serum. In either form of congestion, 
extravasations of blood are frequent. 

Symptoms. — Spinal congestion is announced by pain in the region of 
the spine, usually in the lumbar, or dorsal and lumbar portions, and irradi- 
ations of pain, and tingling in the legs. In addition, more or less paraly- 
sis of the bladder and legs may occur. The paraplegia may occur early 
or not till the lapse of several days. In active congestion, the symptoms 
are rapidly developed, and they attain their maximum intensity sooner 
than in the passive form. In passive congestion the development of symp- 
toms is not only more gradual, but they are ordinarily less pronounced, 
and are attended by more fluctuations than in the active form. The pa- 
ralysis, if present, comes on slowly after several days and is incomplete. 
Spinal congestion, especially of the passive form, is apt to be associated with 
cerebral congestion, as for example in tetanus and severe eclampsia, and 
the spinal symptoms therefore coexist with those which have a cerebral 
origin. The duration and the result of a hypersemic state of the spinal 
cord and its meninges, depend largely on the nature of the cause. If it is 
not relieved within a few days, there is strong probability that some other 
serious pathological state has supervened, as meningitis, myelitis, extrava- 
sation of blood, or serous transudation, with softening of the nervous sub- 
stance. 

Treatment. — In the adult, spinal congestion sometimes results from 
the sudden cessation of the hsemorrhoidal or catamenial flow, and the ap- 
plication of leeches or wet cups along the spine is indicated. But in the 
child, the abstraction of blood is seldom required. Nor is the application 
of cold along the spine ordinarily advisable, since it promotes congestion 
of the internal organs, and its debilitating effect is prejudicial to most chil- 
dren who have spinal congestion, since, in most forms of this malady oc- 
curring in childhood, sustaining treatment is required. In active h3'per- 
semia, laxatives are often useful, and rubefacient applications should be made 
along the spine, as by mustard, or by friction with a stimulating liniment. 
In the inflammatory spinal congestion of cerebro-spinal fever, I have em- 
ployed with a very satisfactory result a liniment containing equal parts of 
camphorated oil and turpentine. In both active and passive hyperiemia 
lateral decubitus should be prescribed rather than dorsal. The internal 
use of ergot, in order to diminish the turgescence of the spinal vessels, has 
not been attended by such benefit as to justify us in recommending it. 
On the other hand, bromide of potassium is a remedy of real value, but it 



460 SPINA BIFIDA. 

is more useful iu certain cases than in others. It is signally beneficial in 
those eases in which there is also cerebral congestion. When the conges- 
tion is increased or produced by clonic convulsions, the bromide is the 
most reliable remedy which we possess for the removal of the cause. Thus 
it should be employed in the treatment of the spinal and cerebral conges- 
tion in the commencement of variola, in which convulsions are so common, 
and in the convulsions of pertussis, which cause extreme passive congestion 
of the cerebro-spinal axis. Passive congestion of the spine, common in 
exhausting diseases, and due to feebleness of the circulation, is best treated 
by stimulating and sustaining remedies, and by the lateral decubitus. It 
is hypostatic, and may be associated with a similar congestion iu the pos- 
terior part of the lungs. 



CHAPTER XVIII. 

SPINA BIFIDA. 

This is one of the most common of the malformations. In its severe 
form it is in its nature incurable, admitting only of palliative treatment, 
while in its milder forms, it may be cured, or so relieved as not to compro- 
mise life. The term spina bifida is applied to a hernia of the spinal 
meninges, Avhich produces a rounded tumor, situated posteriorly over the 
spine in the median line. It is due to the congenital absence or incom- 
pleteness of one or more of the arches of the vertebra. In exceptional 
instances, the arch is said to be complete at birth ; but the lateral portions 
separate, and are pressed outwards during the first weeks of life. The 
tumor contains the cerebro-spinal fluid, and unless it is small, and its walls 
are unusually thick, fluctuation may be detected in it. When the child 
cries the tumor enlarges, and it is reduced by compression, the fluid re-en- 
tering the spinal canal. If the tumor is large, its complete subsidence by 
pressure is apt to produce dangerous cerebral symptoms. Spina bifida is 
the counterpart of hydrocephalus, and the two often coexist. If we com- 
press the hydrocephalic head, the spinal tumor increases, and vice versa. 
Club-foot is anotlier not infrequent complication. In the case which is 
represented in the accompanying woodcut, hydrocephalus, spina bifida, 
and club-foot coexisted. The child was brought to the children's class 
in the Outdoor Department at Bellevue, and after a few visits I lost sight 
of it. It probably died soon after, since the tumor, over which the 
cuticle was wanting, presented a deep-red appearance as if inflamed, so 
that ulceration and escape of the fluid seemed near at hand. There is 
ordinarily but one spina bifida, the common seat of which is the lumbar 



iPINA BIFIDA. 



461 



region, but occasionally there are two or more. If the aperture through 
which the tumor protrudes is small, it is usually pedunculated, but if large, 
it is sessile. In some patients it is covered by skin which may be natural, 
or somewhat indurated ; in others the skin is absent over the entire tumor 
or its most prominent part, and the dura mater or the connective tissue 




lying directly over the dura mater is exposed, and is liable to inflamma- 
tion from friction. If the walls are thin the liquid may transude in drops, 
and opening of the tumor by ulceration or rupture is very liable to occur. 
Sudden escape of the liquid, and collapse of the tumor, involve great 
danger, for convulsions, coma, and death are the probable result. 

The relation of the spinal cord or nerves, or of the cauda equina, to the 
tumor, is a matter of great importance. In many of these tumors the 
entire cord, or the cauda equina, is deflected through the aperture, and 
lies against the interior of the sac. Spinal nerves also not infrequently 
lie within the sac, some returning into the spinal canal, and others passing 
through the walls of the sac to their points of distribution. Those which 
are deflected into the tumor and return into the canal obviously lie lowest. 
In the most favorable cases, namely, those with a small aperture, or small 
tumor, or a narrow and long peduncle, neither the cord, cauda equina, or 
nerves lie within the sac. It is important to the pi'actitiouer to bear in 
mind that in all probability, unless under the favorable anatomical cir- 
cumstances stated above, the sac contains nervous elements. In rare 
instances the liquid, instead of lying externally to the cord, lies within its 
central canal. The substance of the cord then becomes distended, and 
it incloses the liquid like a delicate sac, just as the hemispheres of the 
brain are unfolded and expanded in the common form of congenital 
hydrocephalus. As might be expected from the anatomical characters of 
the more serious forms of spina biflda, paraplegia and paralysis, more or 



462 SPINA BIFIDA. 

less complete, of the vesical and rectal muscular fibres, sometimes occur, 
in which event the fatal issue is probably not far distant. 

Diagnosis. — This is easy in ordinary cases. The congenital nature of 
the tumor, and the bony edge of the aperture, appreciable to the touch, 
suffice in ordinary cases to establish the diagnosis. The diminution of the 
tumor by pressure, and its enlargement wheu the child cries, are important 
diagnostic signs. There are various lumbo-sacral tumors located in the 
median line, from which it is important that spina bifida should be diag- 
nosticated. Sometimes a cyst occurs in this situation which was originally 
a spina bifida, but obliteration of the canal in the pedicle occurred, just as 
the canal connecting a hydrocele with the abdominal cavity closes. Solid 
congenital tumors sometimes also occur in the same situation, among 
which, as most common, may be mentioned fatty tumors, and tumors con- 
taining foetal remains. The most common seat of tumors which inclose 
foetal remains is at the point where spina bifida ordinarily occurs. Physi- 
cians have erred in confounding these tumors, as well as those which con- 
sist of fat, with spina bifida; but a mistake in diagnosis can only occur 
through haste or carelessness of examination. 

Prognosis. — This is in most instances unfavorable. Ordinarily the 
tumor increases slowly, and finally the sac gives way by ulceration or rup- 
ture ; the liquid escapes, and death occurs in convulsions and coma ; or, 
if the escape of the liquid is prevented by pressure, and the aperture 
closes, a second rupture is probable with a fatal result. In other cases the 
tumor may not rupture, but the cord is softened, or it is injured by the 
abrupt bend, so that paraplegia results, and death after a time occurs in a 
state of emaciation. Rarely the tumor may shrivel away by absorption 
of the liquid, and the disease is cured, or so nearly cured that it gives no 
inconvenience, and the patient lives for years. In other rare instances the 
tumor may remain without any material change, and without giving rise 
to symptoms. The spina bifida being small and covered with skin, and 
the aperture leading from it into the spinal canal being also small, the 
patient lives through the natural period of life with little inconvenience. 

Treatment. — It is evident, from what has been stated, that no fixed 
rule can be laid down for the treatment of spina bifida. In the most 
favorable cases, in which no symptoms occur, and there is no indication 
that the tumor will change or undergo any unfavorable change, surgical 
treatment is not required, except the application of a soft pad to support 
the tumor, to prevent its injury by friction. Indications which justify 
active surgical interference are growth of tumor, absence of skin from it, 
with tension of the parietes, so that an early rupture is inevitable, and 
dangerous nervous symptoms, as convulsions or paraplegia. 

From the nature of spina bifida it is evident that operations upon it 
must be conducted with caution. The usual presence of the spinal cord 
in the pedicle and in the sac forbid ligation and excision, and render 



TREATMENT. 463 

liazardous attempts to obliterate the sac by producing inflammation within 
it. A safe mode of treatment, but not the most efficient, is to puncture 
the sac and withdraw a portion of the liquid by a grooved needle or hypo- 
dermic syringe. A soft pad should then be applied to produce gentle 
compression. If no unfavorable symptoms occur, the puncture may be 
repeated after a day or two. This operation has been employed with a 
satisfactory result by Sir Astley Cooper among others ; but, simple as it 
is, it is not devoid of danger, for the removal of the liquid, if carried 
beyond a certain point, may produce dangerous nervous symptoms, espe- 
cially convulsions. In performing the operation, the puncture should never 
be made in the median line, on account of the danger of wounding the 
cord, which lies against the median portion of the sac. The veins, also, 
should be avoided. 

Another mode of treatment is by iodine injections. They are pl-eferable 
to other methods, if the neck is long and pedunculated, so as to be easily 
compressed. If the tumor is sessile, and the apei'ture into the spinal canal 
is free, these injections involve great danger, and are not to be recom- 
mended ; for more or less of the solution will inevitably enter the spinal 
canal, and give rise to spinal meningitis. Iodine injections have been 
employed with success by Professor Brainard, of Chicago, who states that 
he " perfectly and permanently cured " three of seven cases ; and by Vel- 
peau, of Paris, by whose method five in ten operations were successful, and 
by many others. Professor Brainard withdrew some of the liquid con- 
tents, and then injected half an ounce of water containing 2^ grains of 
iodine, and 7J grains of iodide of potassium. In a few seconds this was 
allowed to flow out, and the sac was then washed out with tepid water. 
Then a portion of the cerebro-spinal fluid, which had been kept warm, 
was returned into the sac. When he had withdrawn six ounces of this 
fluid he returned two ounces. In employing the iodine, or any other irri- 
tating injection, it is necessary to compress the pedicle, so that the liquid 
does not enter the spinal canal. Velpeau employed one part of iodine, 
one of iodide of potassium, and ten of distilled water. 

During a debate in the Societe de Chirurgie, M. Debont recommended 
the evacuation of only a little of the fluid, and the injection of two or 
three drops of the tincture of iodine diluted with an equal quantity of 
water ; and T. Smith, by the injection of one drop of the tincture, produced 
an amount of inflammation which nearly obliterated the sac (see Holmes's 
Surg. Din. of Children). Since statistics show so good a result of iodine 
injections, this mode of treatment seems preferable to any other for certain 
cases, and as one drop has produced general inflammation of the sac and 
nearly obliterated it, it seems safest and best to begin with so small a 
quantity. 

If there is reason to believe, from the small size of the orifice and other 
anatomical characters, that neither the cord, cauda equina, nor any of the 



464 VERTEBRAL CARIES. 

spinal nerves, lie within the sac, it may be thought best to remove the 
tumor. It has, indeed, been proposed to open the tumor, immersed under 
warm water sufficiently to observe the relation of the nervous elements, 
and to press them back genth' into the canal if they lie within the sac. If 
it is decided to remove the spina bifida, a clamp, or elastic band, is placed 
around the pedicle so snugly as to cause firm adhesion of the walls of the 
pedicle, and excite sufficient inflammation in them to produce agglutina- 
tion, but without causing strangulation or suppuration. 

After a time, perhaps two or three days, when it is evident that agglu- 
tination has occurred from the fact that the liquid cannot be returned with- 
in the spinal canal by compressing the sac, the tumor may be removed by 
the knife or ecraseur. Statistics do not show so favorable a result of this 
operation as of the iodine treatment, and the reason is obvious, for it is 
only iu exceptional cases that the tumor can be removed without injury to 
the nervous tissue, and excision of a portion of the cord, or of important 
nerves, either produces death or a condition to which death would be a 
relief 

Spina bifida has also been treated by opening the sac on its side, pressing 
back the spinal cord or its nerves into the spinal canal, uniting the edges 
of the wound, and then applying pressure to prevent protrusion, but the 
result has not been favorable. Treatment by simple puncture, followed by 
compression, and if it fail, as it probably will, the cautious use of iodine 
injections, is the preferable mode of treating ordinary cases of spina bifida, 
which require surgical interference. 



CHAPTER XIX. 

VERTEBRAL CARIES. 

Vertebral caries, designated also Pott's disease, occurs chiefly in child- 
hood, but now and then adults are affected with it. It is an osteitis of the 
bodies of one or more vertebrie, ending in their ulceration and a lifelong 
deformity, if not checked. 

Causes. — A reduced state of system, and especially the scrofulous dia- 
thesis strongly predispose to caries. Hence this malady is more common 
in the city than in the country, where better hygienic conditions produce 
a more vigorous constitution. Masturbation has also been assigned as a 
cause. It certainly may be a predisposing cause from its lowering effect 
upon the system. In certain cases, there is no apparent exciting cause, 
while in others there is the history of a fall upon or some injury of the 
spine. 



CAUSES. 465 

. Vertebral caries may occur in the cervical, dorsal or lumbar portions of 
the spinal column, but it is more common in the lower dorsal than else- 
where. With the development of the osteitis, the body of the vertebra 
which is affected, becomes hypersemic, and the spongy tissue is soon infil- 
trated with blood and pus. The bone becomes swollen and softened, and, 
therefore, less resisting than in the healthy state, so that it yields under 
the weight of the shoulders and head, which it sustains. Therefore, after 
the osteitis has continued a certain time, there begins to be posterior con- 
vexity or rather angularity of the spine, for while the vertebral bodies 
soften and yield by the weight above them, the arches retain their integrity 
and firmness, and are unyielding. 

Much of the tediousness and suffering of this malady is due to the fact 
that the inflammation is so deepseated, and a healthy bony barrier is in- 
terposed between it and the surface, so that there is no ready escape of the 
pus. It permeates the spongy tissue, filling the cavities produced by the 
softening and absorption of the bone-substance. If the inflammation is of 
small extent, the amount of pus small, the constitution good, and if the 
disease is early recognized and properly treated, the child may recover 
without any fistulous opening, by absorption of the pus, and with little re- 
maining deformity. 

In the large proportion of cases, however, the history is different. The 
disease is not recognized till the stage of deformity, the caries is so exten- 
sive and the pus so abundant, that it escapes between the vertebrae, form- 
ing an abscess external to them, which connects with the interior of the 
vertebrae by a fistulous canal. This abscess if in the cervical region may 
press upon the pharynx or oesophagus, or upon the air-passages, producing 
dangerous obstruction to the resj)iratiou. (See Art. Retro-pharyngeal 
Abscess.) The pus may point and discharge externally near the seat of 
the caries, but in a large pi-oportion of instances it takes a long and cir- 
cuitous route to the surface, or it opens internally. There are instances 
in which it discharges into the pleural or abdominal cavity, or into one of 
the abdominal organs. If, as is sometimes the case, it establishes a con- 
nection with the intestine and escape in the stools, the result will probably 
be favorable. In other instances it descends into the pelvic cavity, and 
finds an outlet by the inguinal ring, or sciatic notch, or it enters the sheath 
of the iliacus or psoas muscle, and points externally. 

When the disease ends favorably, new bone is thrown out around the 
diseased vertebrae, preventing any farther bending, and giving stability to 
the spine. If the abscess do not discharge, but remains subcutaneous, Bill- 
roth says : . . . " While the bone disease recovers most frequently, a large 
part of the pus, whose cells disintegrate into fine molecules, is absorbed, 
while the inner walls of the abscess change to a cicatricial tissue, which in 
the shape of afibrous sac contains the puriluiin fhiid. Such j)us-sacs ol'teu 
remain in this stage for years." 

30 



466 VERTEBRAL CARIES. 

If the pus has escaped externally, the abscesses and fistulte contract and 
finally close, their site being occupied by condensed connective tissue. The 
portions of the diseased vertebrae which have retained their vitality are 
enveloped and supported by the new bone, so that the part of the spine 
which was the seat of the disease, though anchylosed and curved, has greater 
firmness than in health. 

The progress of unfavorable cases varies considerably. The caries may 
extend, portions of bone floating in the pus, while the general health foils, 
and purulent absorption or tuberculosis may supervene. Death may occur 
from meningeal, bronchial, or pulmonary tuberculosis. 

Spinal meningitis in the vicinity of the caries, and due to extension of 
the inflammation, is common, and "the spinal medulla," says Billroth, 
" may be endangered by participation rn the suppuration, or by being so 
bent by the inclination of the vertebrse, that its function is destroyed." 
Hence the paralysis of the lower extremities, bladder, and rectum, which 
occurs in aggravated cases, and which entails a fatal issue. In a certain 
proportion of cases the blood becomes more and more impoverished from 
the continuance of the inflammation and suppuration, and death occurs in 
a state of exhaustion. In such cases post-mortem examination often dis- 
closes waxy degeneration of important organs, as the spleen, liver, kid- 
neys, and intestines, for it is well known that chronic suppurative inflam- 
mation of tli,e bones and constitutional syphilis are the two chief causes 
of the waxy disease. 

Symptoms. — Caries of the vertebra? is often preceded by symptoms or 
appearances which are due to the strumous cachexia. Strumous ailments 
have probably occurred in the patient, or in members of the family, 
or without any clear history of struma, the child has perhaps for some 
time been in failing health. In cases which I have observed, one of the 
chief symptoms, and sometimes almost the only symptom in the com- 
mencement of the caries, has been neuralgic pain, usually not severe, in- 
termittent, or more or less constant, at some point in the anterior aspect of 
the body, most frequently in the chest, epigastric or umbilical region. This 
pain has been present in a larger proportion of cases, than pain in the 
spinal region at the seat of the caries, though Guersant dwells particularly 
upon the latter as a symptom of caries. Patients with this neuralgia are 
not infrequently treated for indigestion, or worms, the true nature of the 
malady not being suspected, and the spine not even being examined. 
This neuralgia seems to be due to compression of the spinal nerves, by 
inflammatory exudation at the points where they emerge from the spinal 
canal. I can recall to mind a number of cases, in which I have on dif- 
ferent occasions been asked to prescribe for this neuralgia, which was 
shown by the sequel to be undoubtedly the result of vertebral caries, and 
yet with a careful examination of the spinal column could discover no evi- 
dence of disease at any point. After a time, tenderness, pain, and inflam- 
matory induration, appreciable to the touch, may occur in the spine, but 



DIAGNOSIS — PEOGNOSIS. 467 

not usually till the malady is well advanced. Lassitude, fatigue .after 
slight exertion, poor appetite, Avith little or no appreciable fever, are com- 
mon symptoms in the first stage of the caries. 

As the case advances, if the nature of the disease is not recognized, and 
no artificial support of the trunk is provided, the child instinctively seeks 
some way of supporting the head and shoulders. He rests his head upon 
his hands, or his elbows upon the table. Soon a gibbosit3'- or angularity ap- 
pears, affording clear and positive proof of the nature of the disease. Even 
now there is little or no tenderness when pressure is made directly on the 
spine, but it is observed more when pressure is made laterally upon it. If 
the inflammation extends so as to involve the meninges and the cord, prick- 
ing, tingling, numbness or weakness of the legs may occur, which are symp- 
toms of grave import, for it is pi'obable that the case will end in para- 
plegia and death. A state «f emaciation and general weakness, sometimes 
accompanied by diarrhoea and oedema of the limbs, precedes death. But 
a very considerable degree of curvature is not incompatible with a healthy 
and normal performance of all the functions, and the number who recover, 
and live to an advanced age with great deformity, is large, as every one 
knows. 

Diagnosis. — This is often from the nature of the disease obscure and 
uncertain for a time. The long continuance of pain in the chest or abdo- 
men, or perhaps in the thighs, without any cause, which we can detect, 
located at the seat of the pain, should excite suspicion of spinal disease. 
Such pain maybe produced by spinal irritation, but in this malady pressure 
on the spine is badly tolerated, and when we touch a certain part, the neu- 
ralgic pain is intensified. In caries, as we have seen, firm pressure upon 
the spine is tolerated, and it does not increase the neuralgia. At a later 
period in caries, there maybe spinal pain and tenderness, but there is now 
also spinal deformity, by which alone the diagnosis is clearly established; 
stifl^ness observed in the movements of the spine, pain in the spine, on 
sudden movement or jarring the body, impaired appetite and general 
health, and instinctive desire to sit or recline in such a way as to relieve 
the spine partially of the weight of the head and shoulders, are symptoms 
which, if they coexist, afford very strong evidence of the presence of caries, 
although there is as yet no deformity. 

The spinal deformity of rachitis is distinguished from that of caries, by 
the fact, that it occurs slowly without pain or tenderness, and is rounded 
instead of angular. Moreover, the rachitic diathesis precludes scrofulous 
ailments, and the scrofulous diathesis rachitic ailments, as the two diatheses 
do not coexist or but rarely ; so that if there are in the state of the patient 
or have been in his history evidences of scrofula, the presumption is that 
the bending of the spine occurs from caries. In a case of rachitis curvature, 
we find also enlargements of the ankles and wrists, heel-shaped thorax, 
prominent abdomen, rachitic head, etc. 

Prognosis. — The course of this malady, even when the caries is slight 



468 VERTEBRAL CARIES. 

and the symptoms mild, is tedious. lu the most favorable cases, the 
general health is but slightly impaired, the caries confined to one vertebra, 
and is early diagnosticated and properly treated. On the other hand, if 
the general health is decidedly poor, the child ansemic and wasted, the 
curvature great, and an abscess has occurred, the case is very serious. 
Between these two extremes is every gradation. The prognosis is more 
favorable in the child than in the adult. The £e\f adults whom I have 
seen with it all died. It is less favorable in the cervical region than in 
the dorsal or lumbar. A mild case occurring in a good condition of health, 
may become grave and even fatal by neglect and improper treatment. A 
majority of the patients, if the disease is not too far advanced when recog- 
nized, recover if properly treated, but the deformity which results may 
prove serious in after-life. The incomplete expansion of the lungs in the 
humpbacked, greatly increases the danger and the dyspnoea in bronchitis 
and pneumonia, and if the caries has been at a low point in the spine, and 
the patient a female, the deformity will probably present an obstacle to 
childbearing. 

Treatment. — The treatment must be constitutional and local, hygienic, 
medicinal, and mechanical. It is of the utmost importance to improve the 
general health, as it is in all chronic inflammations and scrofulous ailments. 
Pure air, sunlight, personal cleanliness,, and plain but the most nutritious 
diet are required. Tonic and anti-strumous remedies are indicated. To 
many patients I have prescribed, three times daily, cod-liver oil, to which 
the syrup of the iodide of iron was added, giving two drops to a child of 
one year, and one additional drop for each additional year. The judicious 
use of alcoholic stimulants will often be found useful, if the appetite is poor, 
and general health seriously impaired, as will also the vegetable bitters. 

In all strumous inflammations of the bones, which extend to or involve 
joints, and which are in their nature chronic, perfect quiet of the parts, so 
far as it is consistent with the degree of exercise which is required in order 
to improve the appetite and general health,, is indispensable for successful 
treatment of the case. The patient with this malady should be encouraged 
to lie much of the time in bed, for the double purpose of preventing move- 
ments of the inflamed vertebrae, and of relieving them of the weight of the 
shoulders and head. But confinement in bed is badly tolerated, and exer- 
cise is necessary for a healthy functional activity of the organs ; therefore 
mechanical support of the spine is required. The apparatuses which have 
been invented for the purpose of supporting the spine and rendering it im- 
movable, and of sustaining the head, if the caries is in the cervical region 
or the head and shoulders, if it is in the dorsal or lumbar region, are in- 
genious and effectual. Some of them are rather cumbersome, but others 
are sufficiently light for the youngest child who can walk. The apparatus 
should be worn for months, care being taken to prevent excoriation or un- 
due pressure upon any point. It may be removed at night, and reapplied 
on rising in the morning. 



SECTION 11. 

DISEASES OF THE EESPIRATORY SYSTEM. 

CHAPTER L 

CORYZA, 

The term coryza is applied to inflammation of the Schneiderian mem- 
brane. It is acute or chronic. The acute form is primary or secondary. 
Acute primary coryza is common in infancy and childhood. Its usual 
cause is exposure to currents of air, to cold, and especially to sudden 
changes of temperature fi-om warm to cold. The cause is the same as 
that in the ordinary forms of bronchitis. These two diseases frequently 
indeed coexist, occurring from the same exposure. The inflammation in 
such cases commences upon the Schneiderian membrane, immediately 
upon the operation of the cause, and soon after extends to the bronchial 
tubes. Acute coryza may also be produced by the inhalation of irritating 
vapors, hot air, or dust, and also by the presence of a foreign body, as a 
button or bean, in the nostril. 

Secondary coryza is commonly due to a specific cause. The diseases in 
connection with which it occurs are hooping-cough, measles, scarlet fever, 
diphtheria, and constitutional syphilis. In the infant, coryza is one of 
the first manifestations of hereditary syphilitic taint. 

Acute primary coryza ordinarily abates in from one to two weeks. The 
secondary form gradually declines, in most cases, when the primary affec- 
tion on which it depends is cured. Syphilitic coryza is more protracted 
than the primary form, or than that accompanying the eruptive fevers. 
Some children are so liable to coryza that it occurs whenever they take 
cold. Occasionally it is so frequently reneAved in the winter months that 
it resembles the chronic form of the disease. 

Chronic coryza is commonly dependent on a dyscrasia. It corresponds 
with chronic inflammation of the external ear, and otorrhoea is not infre- 
quent in connection with it. The dyscrasia is indicated by pallor, flabbi- 
ness of the flesh, and liability to glandular swellings. Chronic coryza 
may also occur in those who have good general health, as the result of an 



470 COEYZA. 

acute attact. Many a case dates back to one of the exanthematic fevers, 
the local affection continuing after the general health is restored. Earely 
chronic coryza comes on gradually and without appreciable cause. 

Anatomical Characters. — The alterations which the nasal mucous 
membrane undergoes when inflamed, vary considerably in different cases. 
In the simplest and most common form of coryza, this membrane is some- 
times in patches, sometimes generally reddened, thickened, and softened. 
Its papillae are prominent,, producing an inequality of the surface. Ulcer- 
ations are not common in simple acute coi-yza, but they sometimes occur 
in the chronic form. 

In diphtheria,, and sometimes in uncomjDlicated scarlet fever and variola, 
the coryza is pseudo-membranous,, and when it presents this form it is 
commonly but not always associated with pseudo-membranous angina or 
laryngitis. A case of pseudo-membranous coryza occurring in measles is 
related by M. Guibert, The patient was a rachitic boy, three and a half 
years old. The pseudo-membrane,, in severe cases, may cover almost the 
entire surface of the nostrils, but ordinarily it occurs in patches. 

Symptoms, — The constitutional symptoms are mild or severe, according 
to the gravity of the inflammation. If the coryza is acute and pretty 
general, there is febrile movement, with thirst and loss of appetite. 
Frontal headache is common,, from the proximity of the inflammation to 
the head, or its extension to the frontal sinuses. Sneezing is the first 
symptom in many cases of acute coryza. As the inflamed membrane 
swells, more or less obstruction occurs to respiration. The breathing is 
noisy, especially during sleep,, and in severe cases the patient is compelled 
to breathe mostly through the mouth. If there is much obstruction to 
respiration the suffering of the patient is considerable, from the sensation 
of fulness in the nostrils, the headache, and the muscular effort required 
in each resj)iratory act. 

In the commencement of coryza the jmtient experiences a sensation of 
dryness in the nostrils, which is soon succeeded by a thin discharge of a 
serous appearance. In the course of a few hours the secretion becomes 
thicker. It is muco-purulent, and remains such till the disease begins to 
decline. Inspissated mucus and crusts are apt to collect within the nos- 
trils and around their orifice in chronic coryza, and sometimes also in the 
acute disease, if the discharge is not abundant. These crusts increase the 
diflBculty of breathing. Often the acridity of the discharge is such that 
the skin of the upper lip and around the nostrils is excoriated. 

Prognosis. — Simple, uncomplicated coryza rarely terminates fatally. 
It is only dangerous in young nursing infants, in whom it may seriously 
interfere with lactation. Coryza, accompanying the eruptive fevers, al- 
though it may increase the suffering, does not materially increase the 
danger. Syphilitic coryza subsides when the system is sufficiently affected 
by antisyphilitic remedies. Chronic coryza is sometimes very obstinate. 



TREATMENT. 471 

It may continue for months or years, giving I'ise to a constant, but often 
not abundant, discharge. 

Treatment. — Common mild attacks of coryza require little treatment. 
The bowels should be kept open, the feet soaked in mustard-water, and the 
body should be warmly clothed. Some benefit may be derived from fric- 
tion with camphorated oil over the nose. If coryza commence with symp- 
toms which indicate a pretty severe attack, and there are evidences of 
extension of the disease towards the bronchial tubes, an emetic of syrup of 
ipecacuanha, given at an early period, moderates the severity of the in- 
flammation and may prevent the occurrence of bronchitis. Afterwards a 
simple diaphoretic mixture, as the following, should be given: 

R. S3'rupi ipecacuanhse, ^ij. 
Spirit, aether, nitr., ^j. 
Syrupi simplicis, ^ij. Misce. 

One teaspoonful every three hours to a child of six months. In place 
of sweet spirits of nitre, acetate of potash may be employed in the dose of 
one to two grains for infants ; and if there is decided febrile reaction, from 
half a minim to two minims, according to the age, of tincture of digitalis, 
should be added to each dose. 

In pseudo-membranous coryza the main treatment must be directed to 
the accompanying laryngitis, if, as is usual, the latter affection is present, 
since the coryza is much less dangerous than the other inflammation. 
Still, if it cause any obstruction to the respiration and increase the suffer- 
ing of the patient, it requires attention. The frequent injection into the 
nostrils of a weak solution of chlorate of potash in water, with three or four 
drops of carbolic acid to each ounce, exerts a beneficial effect upon the in- 
flammation, and aids in removing the accumulation of fibrin, mucus, and 
pus. It should be employed several times in the course of the day. Alum 
injections, four or five grains to the ounce of water, are also useful in a cer- 
tain proportion of cases ; or a solution of one of the mineral astringents 
may be employed, as liquor ferri subsulphatis, acetate of lead, sulj^hate of 
copper, or nitrate of silver. The bromine solution described in our re- 
marks on the treatment of croup will also be found useful, injected into 
the nostrils. 

In most cases of pseudo-membranous coryza constitutional measures are 
required, on account of the disease with which it is associated. In cases 
of acute simple coryza, and in the pseudo-membranous, inhalation, through 
the nostrils, of the vapor of hot water or of steam from hops often gives 
relief; occasionally it is an important part of the treatment. Syphilitic 
coryza requires those measures which are appropriate for constitutional 
syphilis. 

Chronic coryza, dependent on a dyscrasia, is best treated by tonic and 
alterative remedies. The various ferruginous preparations, as wine of iron, 



472 SIMPLE LARYNGITIS. 

tincture of the chloride of iron, iron lozenges, may be advantageously em- 
ployed, or the vegetable tonics. If there are pallor, softness of flesh, and 
especially glandular swellings, indicating a scrofulous state of system, the 
syrup of the iodide of iron is useful, with or without cod-liver oil. The 
diet should be nutritious, and the hygienic measures such as invigorate the 
general health. Injections into the nostrils of a solution of alum, five 
grains to the ounce, of nitrate of silver, three to five grains to the ounce, 
or of one of the other mineral astringents, are sometimes useful in connec- 
tion Avith constitutional measures. An excellent formula in chronic coryza, 
for application to parts which can be reached by a camel's-hair pencil, is 

the following : 

R. TJng. hydrarg. nitratis, .^ij. 
Ung. zinci oxid., ,^ij. Misce. 

At the Outdoor Department of Bellevue, this ointment has proved 
more effectual in this disease than any other local remedy. It should be 
applied at least three or four times daily, as far within the nostrils as 



Dr. J. F. Meigs, of Philadelphia, recommends the following ointment in 
chronic coryza, to be applied at night, after the use of injections through 

the day ; 

R. Unguenti hydrargyri nitratis, jss. 
Extracti Belladonna), gr. x. 
Axungiae, ^s.s. Misce. 

" It should be applied," says Dr. Meigs, " after being completely softened 
by a gentle heat, on a camel's-hair pencil, care being taken to apply it 
thoroughly to the surface of the mucous membrane itself, and not merely 
to the outside of the hardened scabs." 



CHAPTER 11. 

SIMPLE LARYNGITIS. 

Simple acute laryngitis occurs at all ages, but it is so common in in- 
fancy and childhood, that it is proper to treat of it in a work relating to 
the diseases of these periods. Like other inflammatory affections of the 
air-passages, it is most common in the cold months, or when the weather 
is changeable. Its usual cause is, therefoi'e, exposure to cold. Protracted 
and violent crying, and the inhalation of acrid vapors are occasional 
causes. Simple, or as it is sometimes designated, erythematous, laryngitis 
also occurs in connection with certain constitutional diseases, among which 



SYMPTOMS. 473 

may be mentioned, measles, scarlatina, and variola. Laryngitis is also a 
common accompaniment of bronchitis, and not infrequently of pneumonitis, 
though its symptoms are apt to be obscured by those of the graver disease. 
It often likewise accompanies pharyngitis, due to extension of the inflam- 
mation. 

Symptoms. — Simple laryngitis produced by the impression of cold, is 
commonly preceded and accompanied by coryza. The initial symptom 
is chilliness, followed by sneezing, and the discharge of thin mucus from 
the nostrils in consequence of irritation of the Schneiderian membrane. 

The commencement of laryngitis is indicated by hoarseness, which is 
apparent when the child cries, or, if old enough, when he attempts to 
speak. There is often in severe cases complete loss of voice, so that speech 
above a whisper is impossible. I have noticed this most frequently in the 
laryngitis which accompanies measles. A cough soon occurs which is at 
first dry aud husky but becomes loose in the course of a few days. Ex- 
pectoration is scanty, unless the inflammation has extended to the trachea 
and bronchial tubes. 

This disease is often accompanied by soreness of the throat, noticed in 
the act of coughing or when the larynx is pressed with the finger. In 
simple laryngitis, when uncomplicated, the respiration remains nearly 
natural and the pulse is but little accelerated. In mild cases the nature 
of the disease is often not apparent as long as the child remains quiet, in 
consequence of the absence of symptoms, but the character of the voice, 
when lie cries or speaks, or of the cough, reveals at once the nature of the 
aflfection. 

Simple acute laryngitis subsides in from one to two weeks. Occasion- 
ally it lasts three or four weeks before the symptoms entirely disappear. 
Death, which is rare, is due to some complication. 

Chronic laryngitis is much less frequent than the acute form. Its 
anatomical characters are similar to those in other chronic inflammations 
affecting mucous surfaces, namely, thickening and more or less infiltra- 
tion of the mucous membrane, increased proliferation and exfoliation of 
the epithelial cells, aud increased functional activity of the muciparous 
follicles. 

In the adult chronic laryngitis is common as one of the lesions of the 
syphilitic or tubercular disease. In the child syphilitic and tubercular 
laryngitis is more rare, but the latter sometimes occurs in connection with 
pulmonary or bronchial tubercles. Such patients are emaciated, aud have 
the ordinary symptoms of tuberculosis. Chronic laryngitis also occurs in 
young children, usually infants, as one of the manifestations of the strumous 
diathesis. I have records of about twelve such cases, mostly nursing in- 
fants. Some of these patients had mild bronchitis, but it was obviously 
subordinate to the laryngitis. Their respiration was noisy and harsh, con- 
tinuing of this character for several weeks and even months. The cough 



474 SIMPLE LARYNGITIS. 

was al.so harsh and loud, conveying the idea of thickening and relaxation 
of the mucous membrane covering the vocal cords. Their respiration was 
not notably accelerated, and the blood was apparently fully oxygenated, 
though the friends were often alarmed by the noisy breathing and cough. 

In this form of chronic laryngitis there is little expectoration, the fever 
is slight or absent, the appetite remains unimpaired, and the general con- 
dition of the child is good. There are from time to time exacerbations, 
and occasionally improvement is such as to encourage the hope of speedy 
cure, but in the cases which I have seen there has not been complete inter- 
mission in the disease till the final recovery. Those patients whom I have 
been able to follow through the disease have recovered in from three or 
four months to one year. 

Chronic laryngitis is to be distinguished from frequent attacks of acute 
laryngitis, which are due to fresh exposures, and also from the laryngitis 
which arises from bronchial tubercles. It is to be distinguished from 
protracted acute laryngitis, which sometimes does not entirely subside in 
less than a month or six weeks, by its longer duration, the greater thicken- 
ing of the inflamed membrane, and more noisy respiration. Certain cases 
of chronic laryngitis result from the acute disease, the inflammation being 
perpetuated by the struma or dyscrasia of the patients. 

Anatomical Characters. — In simple acute laryngitis the mucous 
membrane of the larynx presents the usual appearance of raucous sur- 
faces when inflamed, namely, redness and thickening. It is also somewhat 
softened. Ulcerations rarely, perhaps never, occur in primary acute laryn- 
gitis. When present in chronic laryngitis, the ulcers are small and situ- 
ated upon or near the vocal cords. Tubercular and syphilitic ulcers of 
the larynx are much more rare in children than adults. The inflamma- 
tion in simple acute laryngitis usually extends over the whole surface of 
the larynx, and also to the upper part of the trachea. It may be pretty 
uniform, or more intense in one place than another, and, like other mucous 
inflamnaations, it is accompanied by more or less rapid proliferation and 
exfoliation of epithelial cells. In most cases of simple laryngitis, whether 
acute or chronic, the inflammation extends to the pharynx, producing 
redness and thickening, though generally moderate, of the mucous mem- 
brane which covers it. Examination of the fauces therefore aids in diag- 
nosis. 

In the adult osdema glottidis occasionally results from laryngitis. In 
the child there is little danger that this will occur, in consequence of the 
anatomical character of the larynx. In early life there is but little sub- 
mucous connective tissue in the larynx, and therefore less submucous 
infiltration or effusion during the inflammation. The structural changes 
occurring in simple laryngitis of infancy and childhood relate almost ex- 
clusively to the mucous membrane. 

Treatment, — Simple primary and uncomplicated laryngitis requires 



SPASMODIC LARYNGITIS. 475 

little treatment. Most cases would do well by the employment of suitable 
hygienic measures, without medicines. Benefit is, however, derived from 
the use of demulcent drinks and an occasional laxative. A mixture of 
paregoric and syrup of ipecacuanha, or a small Dover's powder, will re- 
lieve the cough if it is troublesome. If there is restlessness, a warm 
mustard foot-bath is useful. An important part of the treatment is the 
application of some mild counter-irritant over the larynx. In most in- 
stances camphorated oil, preceded perhaps by mustard, produces sufficient 
irritation. It should be rubbed several times daily over the throat, or a 
strip of flannel soaked with it may be applied around the neck. Chronic 
laryngitis dependent on syphilis or tuberculosis requires the constitutional 
treatment which is appropriate for that disease. Local measures have 
but little effect upon this form of inflammation. The chronic laryngitis 
which I have described as occurring chiefly in infancy, and which appears 
to be of a strumous character, is apt to be obstinate. The patient should 
be warmly clothed, and constant care should be taken that there be no 
exposure which would endanger taking cold, as this would inevitably pro- 
duce an exacerbation of the disease, and counteract all that had been 
gained by remedial measures. This form of chronic laryngitis is most 
satisfactorily treated by the application of tincture of iodine upon the 
neck, directly over the larynx, and the internal use of cod-liver oil and 
the syrup of the iodide of iron. Little benefit results in this inflamma- 
tion from the usual expectorant remedies, as squills or senega. 

Spasmodic Laryngitis. 

This is a common disease. It is also called false croup, in contradis- 
tinction to true or pseudo-membranous croup, and, by some of the conti- 
nental writers, stridulous angina or stridulous laryngitis. It should not 
be confounded with spasm of the glottis, which is a form of internal con- 
vulsions, and is not inflammatory. It occurs ordinarily between the ages 
of two and five years. It is commonly a sporadic affection, but Rilliet 
and Barthez state that " it is incontestable that it may prevail epidemi- 
cally." They express this opinion, not from their own observations, but 
chiefly from those of Jurine, made in the commencement of the present 
century. 

Causes. — Children in some families are more liable to false croup than 
in others, so that an hereditary tendency to it must be admitted. The 
exciting cause in most cases is exposure to cold. False croup is not un- 
common in the commencement of measles. Narrowness of the rima glot- 
tidis, and an excitable state of the nervous system, both of which are 
common in early childhood, are predisposing causes. 

Symptoms. — Spasmodic laryngitis is ordinarily preceded for a day or 
two by a slight cough and fever, by symptoms of mild coryza or catarrh, 



476 SPASMODIC LARYNGITIS. 

such as all children are liable to on taking cold. In exceptional cases 
these symptoms are absent and the disease begins abruptly. Singularly, 
it commences in most patients at night, after the first sleep, between ten 
and twelve o'clock. The sleep is usually quiet and natural, but the child 
awakens with a loud, barking cough. There is great dyspnoea, and the 
respiration is harsh or whistling, on account of the narrowing of the 
chink of the glottis from the swelling and tension of the vocal cords. 
The face is flushed and indicative of suffering. The child cries, moves 
from one position to another, Avishes to be held or carried, seeking in vain 
for relief. The skin is hot, pulse accelerated, the voice hoarse or even 
whispering. After a variable period, usually from half an hour to two 
or three — not more than half an hour with proper treatment — these 
symptoms abate. The patient is then somewhat exhausted, and falls 
asleep. The face is less flushed or even pallid, the heat abates, and the 
pulse is less accelerated. The cough, though less frequent, remains for a 
time barking or sonorous, and the respiration, though greatly relieved, is 
not at once entirely natural, but it gradually becomes so. Often there is 
no return of the spasmodic respiration and cough, but sometimes the at- 
tack is repeated once or more, especially during the subsequent nights. 
The symptoms vary greatly in intensity in different patients. 

As the attack declines, the disease, losing its spasmodic character, be- 
comes a simple inflammation. In some patients there is immediate return 
to perfect health, but ofteuer the inflammation extends not only into the 
trachea, but also into the larger bronchial tubes, and there remains a 
tracheo-bronchitis which gradually declines. 

The termination is not always so favorable. Spasmodic laryngitis is, 
in exceptional instances, the precursor of other serious affections, which 
may prove fatal. It has been stated that measles often begins with spas- 
modic laryngitis. Bronchitis becoming capillary, may occur in connection 
with it, as may also pneumonia, and by either of these severe inflamma- 
tions the prognosis may be rendered doubtful. There are a few cases on 
record in which it is believed that spasmodic laryngitis was of itself fatal. 
In some of these cases the dyspnoea was extreme and persistent, and was 
the cause of death. In a case reported by Rogery, on the other hand, the 
respiration became easy before death, and the pulse more and more fre- 
quent and feeble. Death apparently occurred from exhaustion. It is not 
improbable that, had cai'eful post-mortem examinations been made in those 
cases of spasmodic laryngitis which have ended fatally, other lesions would 
have been discovered besides those located in the larynx, perhaps tracheo- 
bronchitis, with an accumulation of mucus in the larynx, producing suffo- 
cation, or perhaps in some eases congestion of the brain or lungs and serous 
effusion. 

Anatomical Character — Pathology. — The opportunity does not 
often occur of* determining the anatomical characters of spasmodic laryn- 



DIAGNOSIS. 477 

gitis. I have witnessed but one post-mortem examination. A little girl, 
nine years old, was taken on Friday night with cough and dyspnoea, indi- 
cating a pretty severe attack. The mother, acting through the advice of 
a friend, gave kerosene oil to her in considerable quantity. This was suc- 
ceeded by obstinate vomiting and purging, which continued during Satur- 
day and Sunday, and terminated fatally on Monday. At the autopsy we 
found uniform and intense injection throughout the whole extent of the 
larynx and trachea and in the bronchial tubes, but there was no pseudo- 
membrane on the inflamed surface, and but little mucus and pus. The 
solitary follicles of the intestines and Peyer's patches were tumefied, and 
the gastro-intestinal surface was injected in places. The cause of death 
was obviously the diarrhcea, apparently of an inflammatory character, and 
probably produced by the kerosene oil. The condition of the mucous 
membrane of the larynx was that which is ordinarily present in spasmodic 
laryngitis, though in some cases in which post-mortem examinations have 
been made the evidences of laryngeal inflammation were slight. Guersant 
relates a case in which the surface of the larynx seemed to be nearly in 
its normal state. Death in cases of slight laryngitis is due to causes which 
are independent of the larynx. In Guersant's case there was tuberculosis. 

There is, as has already been intimated, another and an important 
element besides the inflammation in the pathology of spasmodic laryn- 
gitis — an element producing those phenomena which render it a disease 
distinct from simple laryngitis. I refer to spasm of the laryngeal muscles. 
This element pertains to the nervous system, so that spasmodic laryngitis 
is allied both to the neuroses and to the inflammations. 

Diagnosis. — The disease for which spasmodic laryngitis is most fre- 
quently mistaken is pseudo-membranous croup. The friends, indeed, 
usually make this mistake in forming their opinion of the case before the 
physician arrives ; and there can be no doubt that many of the cases which 
physicians have published in medical journals as true croup w.ei'e ex- 
amples of this affection. The points of differential diagnosis are the fol- 
lowing : True croup begins with symptoms which at first are slight, so as 
scarcely to arrest attention, but which gradually increase in intensity. The 
cough becomes more harsh, and the respiration more difficult, by degrees. 
This increase in the gravity of the symptoms occurs by day as well as by 
night. On the other hand, false croup, though preceded by symptoms of 
coryza, or catarrh, begins abruptly. The symptoms have from the first 
their maximum intensity, and the time at which it commences is the night. 
Again, the cough in spasmodic laryngitis possesses a loud, sonorous char- 
acter ; while in true croup it is harsh or rough, from the presence of the 
membrane, and having, therefore, less fulness. The voice in spasmodic 
laryngitis may be hoarse, but it is not lost, or is lost only for a short time. 
It afterwards becomes natural, or is slightly hoarse. On the other hand, 
in true croup, the voice, from being natural at first, is gradually ex- 



478 SPASMODIC LARYNGITIS. 

tiuguislied. In fatal cases it soon becomes whispering, and continues such 
till the close of life ; in those that recover, the voice remains hoarse for 
several days. These differences are important, and, if fully appreciated, 
are in most instances sufficient to establish the diagnosis. Besides, in a 
large proportion of cases of true croup, portions of the pseudo-membrane 
may be discovered on inspecting the fauces, and the faueial surface is 
deeply injected, while in spasmodic laryngitis there is, with rare excep- 
tions, no false membrane upon the surface of the fauces, and but a moder- 
ate amount of congestion. 

Laryngismus stridulus, or internal convulsions, must not be confounded 
with this disease. It is not inflammatory, but purely spasmodic, suddenly 
commencing and abating — identical, it is believed, in character, with tonic 
convulsions of the external muscles, but affecting the internal muscles of 
respiration. This disease has already been fully described. 

Prognosis. — Little need be added, as regards the prognosis, to what 
has already been stated. While a favorable opinion in reference to the 
result may ordinarily be expressed, the physician should not forget the 
fact that death may occur. Symptoms indicating an unfjivorable termi- 
nation are : great and continued dyspnoea, not diminished by the proper 
remedial measures ; stridulous expiration as well as inspiration ; lividity of 
the prolabia and fingers; pallor and coldness of surface ; pulse progressively 
more frequent and feeble. Convulsions and coma may also occur near the 
close of life. 

Treatment. — The indications of treatment are twofold : first, to relieve 
the spasmodic action of the laryngeal muscles; secondly, to cure the laryn- 
gitis. To meet the first indication, a warm bath of the temperature of 
about 100° should be employed as "soon as possible after the commence- 
ment of the attack. The patient should be kept in it ten or fifteen minutes, 
in order to obtain its full relaxing effect. In mild cases a warm foot-bath 
may be sufficient. A second means is the use of an emetic, which should 
be simultaneous with the bath. To children under the age of three years, 
syrup of ipecacuanha should be given, in doses of one teaspoonful, repeated 
in twenty minutes, till vomiting occurs ; or alum and syrup of ipecac- 
uanha, two drachms of the former to one ounce of the latter, may be given 
in the same dose. The alum and the syrup produce more prompt emesis 
than the syrup alone. Children over the age of three years, unless of 
feeble constitutions, are best treated by the compound syrup of squills in 
teaspoonful doses, or a mixture of this with syrup of ipecacuanha. It is 
not often necessary to give more than three or four doses, and sometimes 
one or two are sufficient to produce vomiting. 

In most cases, by the use of the warm bath and the emetic, the symp- 
toms are rendered milder, and convalescence soon commences. 

In the American Journal of the Medical Sciences, April, 1867, Dr. R. R. 
Livingston reports a case of laryngitis treated by Squibb's ether. It is 



I 



TEEATMENT. 479 

stated that portions of pseudo-membrane, from one-eighth to three-fourths 
of an inch in length, were expectorated ; but the symptoms certainly indi- 
cated a spasmodic element as decided as in spasmodic croup, and the bene- 
fit from the ether was apparently due to the relaxation of the laryngeal 
muscles which it produced. The treatment of the patient, who was two 
years old, was commenced by the administration by the mouth of half a 
teaspoonful of the ether, and followed by its inhalation. " In precisely 
eight minutes from the time the patient commenced the inhalation, the 
abnormal muscular exertion ceased ; a general relaxation took place ; the 
pulse (which had numbered 150) fell to 100." Ether, judiciously em- 
ployed, will probably prove to be a useful remedial agent in spasmodic 
forms of laryngitis, whether or not it has any effect on pseudo-membranous 
formations. A large majority of cases, however, recover speedily without 
its employment, by the other measures recommended. 

To fulfil the second indication, namely, the cure of the inflammation, as 
well as to control the spasm of the laryngeal muscles, bloodletting has 
sometimes been resorted to. It is, however, so seldom required, that it 
may be almost discarded as a part of the treatment. In those of full 
habit, with strong pulse, if the measui-es already recommended should not 
give reliefj one or two leeches might be advantageously applied to the top 
of the sternum ; but except in such cases, local bloodletting, and much less 
general, should not be resorted to. 

Attention should always be given to the state of the bowels in spasmodic 
laryngitis. If they are not well open, a purgative should be administered. 
For those that are robust, and with considerable febrile movement, the 
saline cathartics are ordinarily preferable, as Rochelle salts, or a purgative 
dose of calomel may be administered. The cathartic should not be pre- 
scribed till the nausea from the emetic has subsided. By its derivative 
effect, it tends to diminish the laryngitis, and, in severe cases, it may ob- 
viate the need of depletion by leeches. 

Inhalation of the vapor of hot water, and the application of a sinapism 
over the neck and upper pai't of the sternum, followed by an emollient 
poultice, are useful adjuvants to the treatment. 

When the spasmodic element in the disease is relieved, the case becomes 
one of simple laryngitis, and the general plan of treatment recommended 
for that disease is proper for this. Small doses of ipecacuanha, or of one 
of the antimonial preparations, as the compound syrup of squills, not suffi- 
cient to cause nausea, should now be given at regular intervals. I have 
sometimes added to the expectorant one drop of the tincture of aconite 
root for robust children over the age of three or four years, having a full 
and rapid pulse, flushed face, and other evidences of active febrile move- 
ment. Its effect should be watched, and it should be discontinued when 
its sedative influence on the circulation begins to be apparent. It should 



480 SPASMODIC LARYNGITIS. 

not be given in the spasmodic laryngitis ^vhich occurs in the commence- 
ment of measles. 

If, however, there is not a speedy termination of the disease by recovery, 
or, more rarely, by death, there is nearly always tracheo-bronchitis, or a 
more serious affection, coexisting with the laryngitis, or following it ; there- 
fore, depressing measures should not be long continued. Expectorants of 
a stimulating character, as carbonate of ammonia, or syrup of senega, are 
required in the course of a few days, and in young and feeble children 
they should be given at an early period. 

The mode of treatment recommended above is appropriate for that large 
class in whom the inflammatory element predominates. In a smaller number 
of cases the nervous element predominates over the inflammatory, and the 
treatment should be in some respects different. Such children are usually 
pallid and of spare habit, having, indeed, the nervous temperament. They 
are liable to attacks of this disease, though generally of a mild form, on 
slight exposure to cold, and with a very moderate amount of inflammation. 
The treatment in these cases should be directed more to the nervous system. 
My plan has been, in the treatment of such cases, after perhaps the use of a 
mild emetic, to give quinine, one grain three or four times daily, to a child 
from three to five years old, prescribing at the same time a simple expecto- 
rant, as syrup of squills, and a mildly irritating application to the throat. 
The symptoms in these cases are not severe, and active measures are not 
required, though the peculiar cough continues longer than in the more in- 
flammatory forms of the disease. 

The patient with spasmodic laryngitis should be kept in a warm room dur- 
ing the paroxysms, and should inhale an atmosphere loaded with moisture. 

Trousseau recommends a mode of treatment of spasmodic laryngitis which 
was first suggested by Graves, of Dublin. It consists in the application 
underneath the chin, so as to cover the larynx, of a sponge soaked in water 
as hot as can be borne ; in ten or fifteen minutes it is repeated. This reddens 
the skin, producing revulsion from the larynx. The hoarseness, dyspnoea, 
and cough diminish with this treatment, and some recover without other 
measures. 

Guersant and others speak of the importance of prophylactic manage- 
ment of children who are liable to this disease. Attention should be given 
to the dress, so that there may be suflicient protection from changes of tem- 
perature, and there should be an equable temperature of the apartments 
in which they reside. Children of a decidedly nervous temperament, in 
whom the slightest laryngitis is apt to be spasmodic, require additional 
prophylactic measures. They are pallid, and in a more or less cachectic 
state. Such children are benefited by chalybeate and vegetable tonics, 
and by exercise in suitable weather in the open air. 



PSEUDO-MEMBRANOUS LARYNGITIS. 481 

CHAPTEE III. 

PSEUDO-MEMBRANOUS LARYNGITIS, 

The term pseudo-membranous laryngitis, or true croup, is applied to a 
common and fatal disease, the essential anatomical character of which is 
inflammation of the mucous membrane of the larynx, with the formation 
upon its surface of a pseudo-membrane. It occurs most frequently between 
the ages of two and seven years. It is rare in adult life, and also under 
the age of six months. 

Causes. — There is greater liability to this disease in some children than 
in others, and occasionally the predisposition to it appears to be inherited. 
The common exciting cause is exposure to cold. Those children, especially, 
are liable to croup, who live in heated apartments, and are taken into the 
open air without proper covering, and those who a part of the time are 
warmly ar^d a part of the time thinly clothed, especially as regards the 
covering of the neck. This disease is common among the poor of New 
York, who live in close rooms, overheated through the day and cool at 
night. Another less common cause is the inhalation of irritating vapors, 
or swallowing irritating or corrosive liquids, I have known a child to die 
from swallowing acetic acid, and another from scalding water, both having 
the dyspnoea and cough of true croup. 

This disease is ordinarily primary, but occasionally it is secondary. The 
secondary form is not unusual in the declining period of measles, and it is 
an occasional complication of scarlet fever. Croup is most common in the 
winter months, and in times of changeable weather. It is said, also, that 
it sometimes occurs as an epidemic, but it is a question whether the sup- 
posed epidemics may not have been diphtheritic. 

Anatomical Characters. — The inflammatory action in this malady 
affects not only the mucous membrane, but, in a certain proportion of 
cases, extends to the submucous connective tissue, causing infiltration or 
oedema. The raucous membrane itself undergoes similar alteration to that 
in simple or spasmodic laryngitis, consisting of hyperseraia and thickening, 
proliferation, and rapid desquamation of its epithelial cells, and an abun- 
dant production of muco-pus. Sometimes the redness is found only in 
patches at the autopsy; in other cases it extends over the whole surface of 
the larynx, while occasionally it has disappeared, so that the laryngeal 
mucous membrane, though thickened and softened, presents nearly its 
normal color. In all except the mildest cases the inflammation extends 
further than the larynx, involving not only the surface of the pharynx, 
but also in greater or less degree that of the trachea and bronchial tubes. 

The distinguishing feature as regards the anatomical character of this 

31 



482 PSEUDO-MEMBRANOUS LARYNGITIS. 

disease remains to be uoticed, namely, the false membrane which covers 
the laryngeal and often contiguous surfaces. This has long been consid- 
ered as consisting of fibrin, which, exuding in its liquid state from the 
submucous vessels, became fibrillated when exposed to the air, its inter- 
stices being filled with a greater or less amount of pus, epithelial cells, and 
amorphous matter. At a recent date Wagner has surprised pathologists 
by the statement that these pseudo-membranes contain no fibrin, but that 
they consist of epithelial cells, which, undergoing some form of degenera- 
tion as they are pushed forward from the mucous surface, enlarge, and 
appear under the microscope as irregular blocks interlacing with each 
other. By employing the picro-carminate of ammonia, or a weak aramo- 
niacal solution of carmine, Weber and other microscopists have been able 
to trace the boundaries of these irregular and interlacing blocks, which 
have prolongations like the shape of a stag's horns, and they have ob- 
served the intermediate forms of transition between these and the normal 
epithelial cells. 

The views of Wagner are now generally admitted to be in the main 
correct as regards the pseudo^membrane of croup, but some of l>he highest 
authorities in pathological histology, as Rindfleisch, state that they find 
fibrin in the pseudo-membrane,, in addition to the enlarged and degenerated 
epithelial cells of which it is chiefly composed. Riudfleisch says : " The 
pseudo-membrane is of a peculiarly stratified structure, since upon a layer 
of cells at tolerably equal distances there always follows a layer of fibrin, 
and this sequence is repeated from one to ten times, according to the thick- 
ness of the membrane." (FatJiolog. HistoL, translated, page 351.) As 
lending support to the views that the pseudo-membrane does contain fibrin, 
the fact may be stated,^ that while in the ordinary pneumonia of young 
children there is no fibrinous exudation in the air-cells, this exudation does 
occur, at least in a certain proportion of cases, in pneumonia occurring as 
a complication of croup. Thus, recently, in this city, in a pneumonic lung 
from a case of fixtal croup, occurring at the age of about two years. Dr. 
Francis Delafield found fibrin in the exudat of the air-cells. The exact 
nature of the degeneration which the epithelial cells undergo is unknown. 
It is generally believed that they are infiltrated by an albuminate, but 
Weber holds the opinion that the substance is fibrin. MM. Cornil and 
Ranvier, on the other hand, state: "We have verified the correctness of 
the description given by Wagner ; we have separated and colored the cells 
by means of the picro-carminate of ammonia, and, in consequence of the 
facility which they present of fixing the carmine, we conclude that they 
are not filled with fibrin, but rather by a matter resembling mucin. These 
exudats of true croup are pressed forward and detached in proportion as 
the globules of pus or new epithelial cells are produced underneath them." 
The pseudo-membrane varies greatly in amount in different cases. It may 
occur only in points or small patches, which are generally found in the 



SYMPTOMS. 483 

vicinity of the vocal cords, while iu other eases it extends an almost con- 
tinuous membrane from the epiglottis into the bronchial tubes, and there 
is every gradation between these two extremes. It fills the orifices of the 
muciparous follicles, and the minute depressions upon the mucous surface, 
being closely adherent, so as not to be detached by efforts of coughing or 
vomiting, except in small portions. 

As the inflammation commonly extends beyond the larynx, so the pseudo- 
membrane, in a large proportion of cases, is formed not only upon the 
laryngeal, but also upon contiguous surfaces. In thirty-three cases of true 
croup, comprised in the statistics of Dr. Ware, of Boston, pseudo-mem- 
branous pharyngitis was also present in all but one ; and in nineteen cases 
observed by Dr. Meigs, of Philadelphia, in all but three. The formation 
of a pseudo-membrane in the trachea in connection with that in the larynx 
is also common, and it is not infrequent in the bronchial tubes. M. Guer- 
sant has, so far as I am aware, collected the largest number of records re- 
lating to the extent of the pseudo-membrane in true croup. In an aggre- 
gate of 120 cases it was confined to the larynx and trachea in 78, or about 
two-thirds, while in the remainder, namely, 42, it extended into the bron- 
chial tubes. 

In those whose systems are robust, the false membrane is usually firmer 
than in those whose systems are reduced. In a state of decided cachexia 
it is sometimes friable and easily detached. If the case continues from 
four to six days, it begins to soften from commencing decomposition, the 
minute fibres which attach it to the mucous membrane give way, and, in 
favorable cases, by the effort of coughing or vomiting, it is thrown off". 
Separation is aided by muco-pus, which collects underneath. In fatal cases 
the false membrane, if detached by the efforts of the child, is rapidly re- 
produced, so that in twelve to eighteen hours the dyspnoea returns. Pneu- 
monia not infrequently complicates croup. In extreme cases, in which 
inspiration is difficult in consequence of the obstruction, the lungs are only 
partially inflated, and imperfect decarbonization of the blood and some- 
times collapse of certain pulmonary lobules are the result. Occasionally 
there is that degree of thickening of the mucous membrane, and submucous 
infiltration, that the dyspnoea and danger occur more from these than from 
the presence of the pseudo-membrane. 

Symptoms. — In some cases, pseudo-membranous, like simple laryngitis, 
is preceded by coryza and pharyngitis, while in others laryngitis is present 
from the first. The commencement of croup is indicated not only by fever, 
diminished appetite, thirst, and such symptoms as accompany all acute in- 
flammations, but by certain other symptoms which serve to distinguish this 
from all other diseases. 

The cough is one of the earliest symptoms which distinguish true croup 
from other laryngeal inflammations. It is hoarse or harsh ; its character 
may be expressed by the term dry or suppressed. It diflfers from the cough 



484 PSEUDO-MEMBRAXOUS LARYNGITIS. 

of spasmodic laryngitis, which is less hoarse and more sonorous. It is much 
more frequent in some cases than in others ; in many patients, towards the 
close of life, it nearly or quite ceases. Hoarseness of the voice is also one 
of the first and most constant symptoms, and it continues throughout. To- 
wards the close of life the voice is usually lost, and the child expresses its 
thoughts in an indistinct whisper. 

The amount of expectoration varies considerably in different patients, 
according to the presence or absence of bronchial inflammation. If the 
inflammation extends no lower than the upper part of the trachea, the 
sputum is scanty during the whole course of the disease. In ordinary cases 
it is scanty at first, then more abundant, and again more scanty if the case 
is fatal. The scantiness of the sputum towards the close of life is due not 
entirely to exhaustion of the patient, but in part to obstruction in the larynx 
above the mucus and pus. By vomiting a much larger quantity is expec- 
torated than by the cough. Frequently small portions of pseudo-membrane 
are expectorated with the mucus and pus, and occasionally also larger 
masses, complete moulds, indeed, of the larynx, trachea, or even of the 
bronchial tubes. 

The respiration is accelerated, but not so much as in pneumonia or capil- 
lary bronchitis. In the advanced stage it commonly becomes slower than 
at first. As the obstruction in the larynx increases, the respiration assumes 
more and more the character which has been designated abdominal ; the 
infra-mammary region is depressed in each inspiratory act, while the larynx 
approaches the sternum, and the alte nasi are dilated. Patients sometimes 
have painful attacks of dyspnoea, due to detachment of an edge of the 
pseudo-membrane, and its doubling upon itself. In the paroxysm, the suf- 
ferer throws himself from side to side in the bed, or reaches his arras to his 
mother or nurse for relief ; his eyes are wild, features anxious, and, in severe 
paroxysms, fingers and prolabia livid. In the interval there is compara- 
tive quietude, though the respiration is constantly embarrassed. 

The frequency of the pulse varies according to the extent of the inflam- 
mation and the stage of the disease. In the commencement of primary 
croup it ordinarily varies from about one hundred and ten to one hundred 
and twenty beats per minute. In the course of the disease it becomes more 
frequent, and towards the close of life feeble. 

Now and then a patient presents a decided remission in symptoms, due 
to detachment of the adventitious layer, and the friends are apt to think 
that the dangei is passed. Unfortunately the lull in symptoms is in most 
cases deceitful, as the cause of the dj'spnoea is rapidly reproduced. I once 
attended a case in which there had been such dyspnoea that an unfavor- 
able prognosis was given. An almost complete intermission, however, 
occurred in the symptoms, with the exception of the febrile movement, so 
that a physician who visited the patient at this time diagnosticated an 
essential fever. In a few hours, the pseudo-membrane being reproduced, 



PATHOLOGICAL CHARACTERS. 485 

the symptoms returned with greater violence than ever, and the child 
died. So complete an intermission seldom occurs in a fatal case ; and in 
most patients, during the times of temporary improvement, there is still 
such dyspnoea, with the characteristic cough, that the nature of the dis- 
ease is apparent. 

If the stethoscope is applied over the larynx in true croup, the loud ex- 
piratory as well as inspiratory sound is heard as the air passes by the ob- 
struction. This sound is often transmitted to every part of the chest, so as 
to obscure the rales which may be produced there. Auscultation over the 
chest reveals either the vesicular murmur, perhaps somewhat diminished 
in intensity, or more frequently the sonorous and afterwards moist rales 
due to coexisting bronchitis. In a limited number of cases, dulness on 
percussion is observed at some part of the chest, with bronchial respiration, 
indicating pneumonia. Kecovery from croup is in most patients gradual ; 
the voice becomes less hoarse, the cough looser, and the dyspnoea ceases by 
degrees. The structural changes which have occurred in the mucous mem- 
bi'ane of the larynx do not disappear till several days after the last pseudo- 
membrane is detached. 

Fatal cases may terminate in two or three days, but their ordinary du- 
ration is from five to fourteen days. Death may result directly from the 
thickness and firmness of the pseudo-membrane, which obstructs the en- 
trance of air. Sudden death in a paroxysm of dyspnoea may occur from 
the detachment of one end of the pseudo-membrane, and its folding upon 
itself. In many patients, death is not due so much to obstruction to the 
entrance of air from the presence of the pseudo-membrane, as to the mucus 
and pus which collect in the trachea and bronchial tubes, and which are 
not expectorated on account of the presence of the pseudo-membrane and 
the feeble expiratory efforts of the child. In a case which was examined 
after death in the Nursery and Child's Hosj^ital of this city, the false mem- 
brane was apparently not sufficient to j)roduce a fatal result, but the air- 
passages below it were nearly filled with muco-purulent matter, which ob- 
structed the entrance of air. 

Pathological Characters. — This disease is then essentially a laryn- 
gitis presenting the lesions of a simple though usually severe mucous 
inflammation, but with a superadded element, namely, the false membrane. 
The coexistence of simple or pseudo-membranous pharyngitis, tracheitis, 
and bronchitis is also, as we have seen, common. The impediment to res- 
piration, which renders croup so dangerous and fatal, is due not only to 
the presence of the false membrane, and to the mucus and pus which col- 
lect below it, but also to the inflammatory swelling of the mucous mem- 
brane and submucous oedema. In addition, there is a neuropathic element 
which increases the dyspnoea, and which most observers consider a spas- 
modic contraction of the laryngeal muscles induced by the inflammation, 
and hence the easier breathing in sleep, and in the general nuuscular re- 



486 PSEtTDO-MEMBRAXOUS LARYNGITIS. 

laxation, which precedes death. Professor Jacobi (Amer. Jour, of Obstet., 
etc., N. Y., May, 1868), however, holds that the state of these muscles is 
one of paralysis rather than spasmodic contraction. In his oj^inion, this 
paralysis " is secondary. It depends on the cedematous soaking of the 
posterior crico-arytenoid muscles following the oedema of the mucous mem- 
brane of the crico-arytenoid folds." * 

In several fatal cases which I have had an opportunity to examine after 
death, I have found the appearance of the lungs quite uniform. They 
were reduced in volume (semi-collapsed) and more or less congested. Cer- 
tain parts distant from the bronchi, especially the edges and thin portions, 
were collapsed completely, and certain lobules also hepatized. I have also 
observed, though in some of the cases my attention was not directed to it, 
distension of the right cavities of the heart with blood, and large thrombi. 
From the nature of the disease, the blood is less oxygenated, and some- 
what darker than in those who die of diseases not involving the respiratory 
apparatus. 

Diagnosis. — The diagnosis of true croup is ordinarily easy. It might 
be mistaken for spasmodic laryngitis, but more frequently spasmodic 
laryngitis is mistaken for it. The differences which will aid in differential 
diagnosis are the following : Commencement abrupt and at night in one, 
gradual in the other; presence in one, absence in the other, of a pseudo- 
membrane upon the surface of the fauces ; fragments of this membrane 
in the sputum in one ; character of the cough ; course of the disease grow- 
ing gradually worse in one, in the other, with few exceptions, rapidly im- 
proving. Trousseau speaks of the liability to error of diagnosis in those 
cases in which spasmodic laryngitis is associated with pseudo-membranous 
pharyngitis. Few physicians hesitate to designate as true croup those 
cases in which there is a croupal cough in connection with false mem- 
brane upon the surface of the fauces, and yet the laryngitis under such 
circumstances may be merely spasmodic. This coexistence of pseudo- 
membranous pharyngeal and of spasmodic laryngeal inflammation is, 
however, probably rare, but its occasional occurrence should be borne in 
mind. 

True croup is readily distinguished from laryngismus stridulus, or inter- 
nal convulsions. Laryngismus stridulus is a purely nervous affection ; it 
occurs suddenly, causing great dyspnoea, or momentary suspension of res- 
piration, without the fever and without the hoarse voice and cough of 
croup. When muscular relaxation occurs, the attack ceases. The differ- 
ence between the two disease is therefore obvious. 

Prognosis. — The great mortality from true croup is universally known, 
and those physicians who report a large number of favorable tases have 
probably mistaken spasmodic croup for this disease. According to the 
statistics of Dr. Ware, nineteen out of twenty die; but with judicious 
t.reatiuent, commenced early, the mortality is probably less than this. 



TREATMENT, 487 

though still great. Increase of dyspnoea, the voice and cough becoming 
more hoarse, and the pulse more accelerated, indicate a fatal form of the 
disease. Attention has already been called to temporary improvements 
which are apt to occur in croup, and lead to an error in prognosis. How- 
ever, improvement continuing more than twelve hours is evidence of the 
decline of the disease. 

The near approach of death is shown by lividity with great restlessness, 
or by pallor and somnolence. If the patient recover from croup, there 
often remains more or less bronchitis or broncho-pneumonia, which re- 
quires treatment, and the laryngitis, when its pseudo-membranous char- 
acter is lost, persists for a time, causing more or less hoarseness and 
acceleration of pulse. 

Treatment. — The importance of early treatment in this disease has 
been sufficiently alluded to. If it has continued two or three days when 
first recognized, the chance of recovery is greatly diminished. As the 
danger in true croup arises from the presence of the pseudo-membrane, 
the indication is to prevent its formation, so far as possible, and to aid in 
its removal when formed. 

Emetics have been and are still much prescribed in the treatment of 
this disease. Properly employed, they produce a good effect, but much 
harm has been done by their injudicious administration. As a rule, the 
depressing emetics should not be given except at the commencement of 
the disease, not later, indeed, than the second day, and not given'at all if 
the patient is feeble or cachectic, or if the croup is secondary, as when it 
occurs in connection with measles or diphtheria. I have known death 
occur almost immediately after the administration of an antimonial emetic 
in the pseudo-membranous laryngitis accompan^dng diphtheria, when 
there was no urgent dyspnoea. 

At the commencement of croup, ipecacuanha or tartrate of antimony 
and potassa may then be prescribed if the disease is primary, and the pa- 
tient in good general condition; but if it is secondary, or the vital powers 
at all reduced, an emetic which is less depressing is preferable, as turpeth 
mineral or sulphate of copper. The emetic promotes the secretion of 
mucus, and a considerable quantity of this substance is usually found in 
the vomited matter, and it may also cause the detachment and expulsion 
of the softer portions of the pseudo-raerabrane. If the child in the in- 
itial stage of croup is under the age of three years, the syrup of ipecacu- 
anha, with or without alum, may be administered in teaspoonful doses at 
intervals of ten or fifteen minutes till the emetic effect is produced, or if 
the age is above three years, the compound syrup of squills may be em- 
ployed instead. But when assured that a pseudo-membrane is forming, I 
prefer in most cases the sulphate of copper, in one or two grain doses, given 
in powder with an equal quantity of ipecacuanha, and repeated in ten 
minutes if the first dose does not produce the desired emetic effect. There 



488 PSEUDO-MEMBRANOUS LARYNGITIS. 

is in most cases more or less relief of the symptoms after the emesis, 
though it may be but temporary. In one ease recently in my practice, 
in which there were at the first visit considerable dyspnoea, distinct croupy 
cough, and a pseudo-membrane on both sides of the fauces, and in which 
I had made an unfavorable prognosis, the parents observing the good 
effect of the first powder, repeated the medicine, contrary to directions, at 
intervals of about two hours, till my visit on the following day, and the 
patient recovered. Two or three powders are, however, ordinarily suffi- 
cient for this preliminary treatment. Turpeth mineral is not inferior in 
its effects to sulphate of copper, and many physicians of ample experience 
prefer it, given in doses of two or three grains. Prof. Fordyce Barker, 
of this city, who prescribes an emetic of turpeth mineral immediately on 
being summoned to a case, states that he has not lost a patient thus treated 
for many years. After prompt and efficient emesis is produced, other 
measures are required. We will speak hereafter of the further employ- 
ment of emetics during the progress of croup. 

Loss of blood is not required in the treatment of croup. The stronger 
cardiac sedatives, as aconite and veratrum viride, may occasionally be 
advantageously employed on the first and second days of primary croup. 
They should only be administered to those that are robust. They should 
not be prescribed after the pseudo-membrane is fully formed, nor in cases 
of secondary croup. Unfortunately the emetic treatment recommended 
above, and which must be considered preliminary, fails to arrest the dis- 
ease in a large proportion of cases. It does seem to diminish the amount 
of false membrane in certain cases, and there is reason to think that it may 
even in some instances prevent its formation, so that the inflammation 
remains a simple laryngitis, though presenting in its commencement the 
characteristic symptoms of croup ; but in other and a large proportion of 
cases the pseudo-membrane becomes fully formed, and continues to in- 
crease. The profession have been long looking for a remedy which, taken 
internally, may, by its effect upon the blood or the inflamed surface, pre- 
vent or diminish the membranous foi^mation, and also for a remedy which, 
employed topically, may liquefy and remove it. The remedy which has 
been and still is most frequently prescribed for the first of these purposes 
is calomel. The ordinary ill-effects of this agent, namely, stomatitis and 
ptyalism, should not deter from its employment if it exerts any control- 
ling influence over a disease so rapid and fatal as true croup. I am of 
opinion that it is useful unless there is that degree of impoverishment of 
the blood and cachexia which would contraindicate the continued use of 
any depressing agent. Calomel probably has no effect upon the false 
membrane ; but it is to be recollected that there are other factors in the 
production of the dyspnoea which it is probable that calomel does aid in 
removing, whether by its derivative effect on the intestinal surface, or by 
some other mode of action not fully understood. Calomel is believed to 



TREATMENT. 489 

be one of the most efficient agents, administered internally, for removing 
the thickening and infiltration of the laryngeal mucous membrane and the 
submucous oedema. I think that I have observed benefit from its employ- 
ment, whether in a single dose of six to ten grains, or in small doses of one- 
fourth to one grain repeated several times in twenty-four hours. The 
calomel may be administered alone, or with ipecacuanha, not in sufficient 
quantity to cause emesis, or in certain cases Avith Dover's powder. It may 
be given from two to four days, perhaps sometimes longer, when it should 
be followed by a mixture of chlorate of potassa or soda and muriate of 
ammonia given frequently. In cases in which the vital powers are re- 
duced, especially in secondary croup, this mixture should be given from 
the first, in place of calomel. The chlorate has a solvent effect, though 
feeble, on pseudo-membranes, and as when taken into the system it is 
known to be eliminated in most of the secretions and excretions, it is not 
improbable that it escapes also from the surface of the larynx in the 
mucus, and therefore comes in contact with the membranous formation. 
The chlorates in frequent large doses sometimes cause salivation. Prob- 
ably the efiect of the muriate is subordinate, but it is believed by thera- 
peutists to increase the mucopurulent secretion, and therefore diminish 
in some degree the turgescence of the mucous membrane. Cases in which 
there is marked and protracted dyspnoea and croupal cough do now and 
then recover with the use of chlorate of potassa or soda and muriate of 
ammonia, either employed after calomel, or without it as the main remedy 
from the commencement of the disease — so many, indeed, that it cannot 
be doubted that they do have some curative effect. The following formula 
may be employed for a child from three to five years of age : 

R- Potas. chlorat., gj. 
Amnion, mnriat., Qij- 
Syr. simplic, ^j. 
Aquas, ^ij. Misce. 

Dose, one to two teaspoonfuls every half hour or hourly, according to 
the urgency of the symptoms. This should be continued regularly night 
and day until the cough becomes looser, or until it is evident from the un- 
favorable nature of the case that it can be of no further service. 

A very important part of the treatment is the inhalation of steam. 
Some of our most experienced physicians consider this more useful than 
all other measures combined. In one of the most severe cases which I 
have met, which terminated favorably, the room w'as so filled with steam 
that water hung in drops from the ceiling. The atmosphere which the 
child breathes should be constantly loaded with moisture, without, how- 
ever, that degree of heat which would add materially to the discomfort of 
the patient or attendants. Moist warm air coming in contact with the 
inflamed surface promotes expectoration and renders the cough looser. 



490 PSEUDO-MEMBRANOUS LARYNGITIS. 

Steam may be produced by placing heated irons or bricks in a shallow 
pan or pail containing a little water, by pouring water upon a heated sur- 
face, or by a spirit-lamp or gas-jet uude^- a pan of water. In order to 
avoid heating the entire room and to concentrate the vapor, the nurse may 
sit with the child under a frame covered with a blanket, and the steam be 
produced underneath. 

A temperature of 75° or 80°, if the atmosphere is loaded with moisture, 
is more readily tolerated than a lower temperature with a dry atmosphere, 
and a temperature at least as high as 75° is required, or too much of the 
vapor is deposited. 

Of late years a very important instrument, namely, the atomizer, has 
been employed in the treatment of laryngitis, whether croupous or diph- 
theritic. I employ, with the most satisfactory results, the atomizer of Cod- 
man & Shurtleff (13 and 15 Fremont Street, Boston), and I am sure that 
few who have used it will be willing to treat this disease without it. The 
water may be medicated with any substance desired without injury to the 
instrument, and without diminishing the amount of spray. A full and 
steady stream of vapor is produced without suction by means of the spirit- 
lamp, and without the uncomfortable necessity of maintaining an elevated 
temperature in the apartment. So great is the amount of spray which the 
atomizer of Codman & Shurtleff generates that the patient soon notices 
the trickling of the liquid upon the fauces. I use for the spray the officinal 
lime-water of the shops, from its supposed solvent effect on pseudo-mem- 
branes, but some physicians use lactic acid for the same purpose. If the 
laryngitis is not too far advanced, the atomizer, whether simple or medi- 
cated water be used, commonly renders the cough looser, the voice clearer, 
and the respiration easier. I am convinced, from my experiences with it 
in the treatment of diphtheritic laryngitis, that the necessity of tracheotomy 
might often be avoided, and many lives saved, by the early and continued 
use of this simple instrument. The inhalation may be continued for hours 
without wearying the child. A saturated atmosphere, while it may cause 
swelling of the pseudo-membrane, appears to render it more friable and 
more easily expectorated. 

It has already been stated that depressing emetics should not be em- 
ployed after the second day, but a period arrives in most cases when 
another class of emetics are required. They are required when the dysp- 
n(pa is urgent, as a means of removing from the air-passages the collec- 
tion of mucus and pus and portions of false membrane which may be 
detached. Those emetics should now be prescribed which operate promptly 
with the least depression. Sulphate of copper is one of the best, if not the 
best, for this stage of croup, and it is usually employed by physicians. A 
child of five years may take one grain dissolved in a little water, and the 
dose be repeated if required in ten minutes. Sulphate of zinc or turpeth 
mineral may be used in the place of the copper. Dr. J. F. Meigs, of Phil- 



TREATMENT. 491 

adelphia, prefers pulverized alum, given in teaspoonful doses, but it is less 
efficient, and I am not awai-e that it possesses any advantages over the 
sulphate of copper. Whatever emetic is employed, its operation may be 
promoted by draughts of warm water. 

It is to be recollected, in the treatment of croup, that the pseudo-mem- 
brane, by commencing decomposition, and by the pus and mucus which 
collect underneath, is more easily detached after a few days, if the patient 
lives, than at first. Therefore the physician should endeavor to sustain 
the vital powers, in order that the cough may have sufficient force to 
separate this substance as soon as its fibres of attachment begin to loosen. 
A patient with croup rarely takes solid food, but he should be allowed 
beef tea, milk, and farinaceous drinks, at short intervals. If there are 
signs of exhaustion, alcoholic stimulants are proper, and fresh air should 
also be allowed so far as is compatible with the inhalation of steam. 

While these general measures are employed, local treatment should not 
be neglected. The profession are not agreed as to the treatment either 
external or internal of the throat. As to external treatment, some recom- 
mend poultices, others cold applications, and others still, irritants. Pro- 
fessor Peaslee, of this city, in a series of papers on the pathology of croup, 
published in the American Medical Monthly, ]854, says of cold applied 
externally: "We consider this of the greatest value and importance. If 
cold applications are efficacious in all cases of external inflammation, they 
are scarcely less so here, where the inflamed surface is so nearly super- 
ficial. Cold must, however, be continuously applied to produce the de- 
sired effect. Applied at intervals, indeed, it rather promotes than retards 
the inflammatory process ; since during the intervals the tempei'ature rises 
above the normal standard, in consequence of the reaction of the chill on 
the surface. Cold water may be constantly dropped from a sponge upon 
a compress laid over the throat of the child; and the latter should be of 
only one or two thicknesses of linen, that evaporation may go on as rapidly 
as possible." 

In ordinary cases cold applied over the larynx is, in my opinion, prefer- 
able to poultices or warm applications. A wide, but thin piece of salt pork, 
made more irritating by dusting powdered camphor over it, may be applied 
over the larynx, so as to cover the neck in front, and over this a bladder 
containing pieces of ice, or ice surrounded by oil silk, to prevent dripping, 
be constantly retained. Ice is, I think, better tolerated when applied in 
this way than when there is no intermediate substance. This mode of ap- 
plying cold I have found more convenient than that recommended by 
Prof Peaslee. The temperature of the neck may be kept constantly below 
the normal standard by ice thus applied. Cold is especially serviceable if 
the child is robust, with flushed cheeks and full and rapid pulse. In sec- 
ondary croup, or croup occurring in feeble states of system, or presenting 



492 PSEUDO-MEMBRAXOUS LARYNGITIS. 

a subacute character, poultices or fomentations to the neck, with moderate 
irritation, may sometimes give most relief. 

Topical treatment of the fauces and larynx has long been recommended 
in croup, and the agent which has been most frequently applied is nitrate 
of silver in solutions varying in strength from ten to forty grains to the 
ounce. It is applied once, twice, or several times daily. Nitrate of silver 
does not dissolve the pseudo-membranes, but it contracts those with which 
it comes in contact, and by the contraction aids in their detachment. 

Topical treatment thus applied is probably of little service, when the 
faucial surface is but slightly inflamed, and there is no pseudo-membrane 
upon it, for in these cases the obstruction is probably not so much in the 
upper as in the lower part of the larynx. But if there is a decided faucial 
inflammation, and especially if there is a pseudo-membrane visible on in- 
specting the fauces, direct treatment applied to these parts may be useful. 
The application of a probang to the interior of the larynx of a child is difii- 
cult, on account of his struggles and resistance, and it may well be doubted 
whether the most skilful operator usually succeeds in accomplishing it. 
But if the instrument do not enter the larynx some of the liquid may 
trickle into it, as is indicated by the severe coughing, which it produces. 

Of late years nitrate of silver has been less frequently employed in the 
direct treatment of pseudo-membranous inflammations, and other sub- 
stances have been used in its place ; among which, prominent mention should 
be made of subsulphate of iron, carbolic acid, and bromine with its com- 
pounds. The following is the prescription which I commonly employ, the 
value of which I have many times had an opportunity to observe, espe- 
cially in diphtheritic inflammations : 

R. Acidi. carbolici, gtt. v-x. 
Liq. ferri subsulphat., giij. 
Glycerinae, Jj. Misce. 
To be applied from three to six hours. 

Bromine is employed in combination with bromide of potassium, as in 
the following formula : 

R. Brominii, ^ij. 

Potas. bromid., gr. xxx. 
Aquae, ^j. Misce. 

This is termed the bromine solution, but it must be considerably diluted 
for use. Twenty to forty drops should be added to one ounce of water, for 
application to the fauces or larynx. Dr. Caro, of this city, employs with 
great success, he alleges, the following formula for dissolving and removing 

pseudo-membranes : 

R. Potas. bromid., _5J. 
Aquie, 5J. Misce. 

To be applied every three or four hours with a camel-hair pencil. Other 



TREATMENT. 



493 



physicians recommend the same, but I have not used sufficiently either 
bromine or its compounds for this purpose, to speak confidently of its effect. 

Unfortunately, as I have already stated, true croup, whatever the thera- 
peutic treatment, is, in a large proportion of cases, a progressive disease. 
The hoarseness of the cough and voice and the dyspnoea gradually increase. 
The pulse, becoming more frequent and feeble, indicates the need of the 
most nutritious food, as the animal broths, and of alcoholic stimulants. 
The danger is, however, from the dyspnoea rather than asthenia. Medicine 
has failed to check the disease, and shall now the expedients of surgery be 
tried — shall tracheotomy be performed ? 

The published statistics relating to tracheotomy in croup are to a con- 
siderable extent unsatisfactory, since we are not informed, as regards most 
of them, at what stage of the disease the operation was performed, and what 
were the evidences of a fibrinous exudation. The most valuable and re- 
liable statistics bearing upon this subject, so far as I am aware, are those 
published by Prof. Jacobi, of this city, in the American Journal of Obstet- 
rics, etc., for May, 1868, and containing the results of the cases which were 
operated" on by himself and Drs. Krackowizer and Voss. These gentle- 
men are known to the profession of New York as careful and judicious 
practitioners, not likely to operate when there was probability of success 
by therapeutic measures, and not likely to mistake simple or spasmodic 
laryngitis for true croup. I have tabulated the statistics of their opera- 
tions : 

Age. Number. Recovered. Died. 

Under 2 years, ... ^ ... 8 1 7 

From 2 to 3 years, 29 5 24 

" 3 to 4 " 26 4 22 

" 4 to 5 " 34 11 23 

" 5to6 " 9 2 7 

" 6 to 7 " 1 1 

" 7 to 8 " 3 3 

10 " 1 1 

Not £riven, 55 15 40 



166 



127 



Time of death after 

operation. 
Within 24 hours, . 


Number of 

cases. 
. 19 


Time of death after 

operation. 

On 5th day, . 




Number of 

eases. 
. 9 


On 2d day, . 


7 


" 6th " . 




. 4 


" 3d " . 


. 16 


" 7th " . 




. 2 


" 4th " 


. 15 


" 9th " . 




1 






From 10th to 31st d 


ly 


, 5 


Total, . 








78 



494 



PSEUDO-MEMBRANOUS LARYNGITIS. 



The following were the causes of death, as given in the records of 73 
cases : 



In operation, 

Apncea from too late operation, 
Apncea, .... 
Anaemia and exhaustion, 
Diphtheria, .... 
Bronchitis, .... 
Broncho-pneumonia, . 



Total, 



Pneumonia, ...... 5 



Broncho-pneumo. and pulm. gangrene, 

Pulmonary oedema, 

Pseudo-membranous bronchitis, 

Tuberculosis, 

Convulsions, 

Emphysema, 



The following table gives the result of tracheotomy in one hundred 
Lses. It is prepared from the statistics of Giiterbach, lately published : 



Age. 
Under 1 year, . 
Between 1 and 2 years, 

2 and 3 " 

" 3 and 4 •' 

" 4 and 5 " 

" 5 and 6 " 

" 6 and 8 " 

" 8 and 9 '« 



Result. 

1 case fatal. 

1 " " 
331 per cent, recovered. 
40 " " 

38^3 " 
444 u 

142 U « 

25 " " 



From conversations which I have had with surgeons of New York, I 
am persuaded that the above tables present a more favorable result than 
could be furnished by the general surgical practice of this city. Most 
New York surgeons, however, seem to shun the operation and regard it 
with ill favor, and, did they operate as frequently as those whose names I 
have mentioned, possibly the result would be better. Statistics in Paris 
probably give nearly the true proportion of successful and unsuccessful 
operations of tracheotomy for croup, as it is performed by skilful and 
careful surgeons. Of 388 cases occurring in the practice of several Pa- 
risian surgeons, 346 died and 42 recovered ; w'hile in the Hopital Saiute 
Eugenie, of 374 operated on, 310 died. (Bouchut.) 

The facts in reference to tracheotomy in croup are the following : The 
majority of those operated on do not recover, but some live who without 
the operation would die. The operation is now more successfully per- 
formed than formerly, as the conditions of successful operation are better 
understood. Those who have operated several times, confess that their 
last cases did better than their first. Trousseau's experience was striking 
and instructive in this respect. No one, probably, ever performed this 
operation for croup more times than he, and, from constantly greater suc- 
cess, he became more and more an advocate of the operation. Trache- 
otomy, if properly performed, does not in any case shorten life, but it 
frequently prolongs it several days. It diminishes greatly the dyspnoea, 
and renders death easy. 



TREATMENT. 495 

The objections to the operation are partly of a moral nature. The 
parents, already in the extreme of grief on account of the suffering and 
probable death of the child, consent with reluctance to an operation which 
promises not cure, but a prolongation of life. Common sympathy with 
the child and regard for the emotions of the parents should certainly 
have an influence in deciding for or against the operation. The first case 
of tracheotomy which I witnessed was such as, if common, would con- 
demn this operative measure entirely. No anaesthetic was given, and, in 
the midst of the struggles of the child, large veins were severed, from 
which an abundant haemorrhageoccurred. The trachea was opened, but 
this was no sooner done than death occurred, partly from the loss of blood, 
and partly from the obstruction to respiration caused by its entrance into 
the bronchial tubes. Such cases are, however, quite exceptional. Death 
rarely occurs during the operation, unless the patient is already moribund, 
and the possibility of such a result should have little weight in our deci- 
sion for or against the operation. 

Few will deny, in the light of statistics, that tracheotomy is, in certain 
cases, proper, and that a physician at times would be culpable if he did 
not strongly urge its performance. There are certain supposed contrain- 
dications. One is age less than two years. It is true that those under 
the age of two years are less likely to recover after the operation than 
those above that age ; still, tracheotomy has now and then saved the lives 
of the youngest infants who have croup. The possibility, therefore, of 
success justifies the performance of the operation, however young the 
infant, when the only alternative is death. In the foregoing statistics it 
is seen that one of eight recovered who were under the age of two years. 

The presence of capillary bronchitis or pneumonia does not positively 
contraiudicate tracheotomy, though it diminishes greatly the chances of a 
favorable issue. Nor is tracheotomy forbidden by the extension of the 
false membrane into the bronchial tubes, since it diminishes the amount of 
obstruction along which the air passes in order to reach the lungs, and the 
muco-pus as well as pseudo-membrane, lying below the point of operation, 
may be expectorated through the aperture. A decidedly asthenic state, as 
after measles or scarlet fever, indicated by feeble pulse and other symp- 
toms of exhaustion, may or may not contraiudicate the operation, whether 
the pseudo-membrane is limited to the larynx and trachea or is more ex- 
tensive. 

The manner of performing tracheotomy and the subsequent treatment 
pertain to surgery, and are described in surgical works. A skilful surgeon 
should, indeed, be employed to perform the operation when it is practi- 
cable. At what time in the course of the disease tracheotomy should be 
resorted to is an important practical question. Trousseau at one time 
recommended it as soon as there were certain evidences of the presence of a 
pseudo-membrane, but in the latter part of his life he did not operate so 



496 PSEUDO-MEMBEANOUS LARYNGITIS. 

early. The correct rule, iu my opinion, is not to operate till there are 
signs that the blood is not sufficiently oxygenated, such as lividity of the 
prolabia and tips of fingers. When these signs occur, it is unsafe to delay 
long. The arrangements should be previously made, that no time be lost. 

It is an interesting fact that a large proportion of those who die after 
tracheotomy die of bronchitis, usually capillary, or of pneumonia developed 
after the operation. These diseases seem to be partly attributable to the 
operation, or, if previously existing, to be aggravated by it. It is believed 
that the introduction into the bronchial tubes and the lungs of cool air, of 
air not warmed by the natural circuit through the nostrils and larynx, 
may be a cause of these inflammatory complications. Sometimes, also, the 
canula by pressure increases the inflammation of the surface on which it 
lies. Therefore, not only does the operation require skill in its perform- 
ance, but much of its success depends on the subsequent management. 
After the operation, the temperature of the apartment should be kept 
constantly at from 85° to 90°, and loaded with moisture. This obviates 
in part, but only in part, the tendency to bronchitis and pneumonia. Con- 
stant attention should be given to the canula, to prevent its filling with 
mucus and pus. Trousseau employed a double canula, which can be 
readily cleaned by removing the internal cylinder. The nurse, when prop- 
erly instructed, can remove this cylinder as often as may be necessary in 
order to clean it. ]\Ir. Lawrence, of London, and, following him, some 
other surgeons, prefer not to use the canula. The edges of the wound are 
kept apart by a wire which passes around the neck, or a little of the 
trachea is removed so as to produce a sufficient aperture. The reader is 
referred for particulars regarding this mode of operating to recent treatises 
on operative surgery. 

After the operation no more niedication is required. The patient should 
be kept quiet and free from excitement. His diet should be mainly liquid, 
and of the most nourishing character. In a few days, if the symptoms 
abate, the aperture may from time to time be closed with the finger after 
the withdrawal of the canula, iu order to ascertain if the larynx is free 
from obstruction. If bronchitis or broncho-pneumonia arise, the oil-silk 
jacket, w"ith counter-irritation to the chest, is required, and stimulating 
expectorants, as carbonate of ammonia and syrup of senega, should be 
ordered. 



BRONCHITIS. 497 



CHAPTEK IV. 

BRONCHITIS. 

Inflammation of the bronchial tubes, or bronchitis, is probably the 
most frequent disease of early life. It is usually associated with more or 
less inflammation of the mucous membrane of the nostrils, larynx, and 
trachea. We designate the disease coryza, laryngitis, or bronchitis, ac- 
cording as one or the other inflammation predominates. Sometimes bron- 
chitis occurs with but slight inflammation elsev/here, and often the coryza 
and laryngitis abate while the bronchitis is still active. 

Bronchitis occurs both as a primary and secondary disease. The 
secondary form is common in connection with measles, hooping-cough, 
pneumonia and pulmonary phthisis, and it is not uncommon in scarlet 
fever, variola, remittent and continued fevers. Bronchitis is acute, sub- 
acute or chronic, and according to its extent it is mild or severe. If the 
smallest bronchial tubes are involved, the inflammation is designated cap- 
illary bronchitis, a term not well chosen, but ^vhich it is convenient to 
employ in a description of the malady. Bronchitis is commonly bilateral, 
affecting the tubes on the two sides with about equal intensity. When 
due to tubercles, or to pneumonia, it is apt to be unilateral, being con- 
fined to those tubes or nearly to those which are surrounded by tubercular 
or inflammatory product. 

Causes. — The causes of secondary bronchitis are obviously the diseases 
in connection with which it occurs. The cause of primary bronchitis is 
the same as that of simple acute laryngitis or coryza, namely, sudden 
change of temperature from warm to cold, exposure to currents of air, the 
practice of sending children without sufficient clothing from heated rooms 
into the open air, the throwing off* of bedclothes at night, etc. Dentition 
is also an occasional cause, since some children have attacks which coincide 
with the eruption of the teeth. The cough of dentition is usually purely 
a nervous affection ; but in other instances it is accompanied by more or 
less mucous secretion, and is evidently dependent on a mild inflammation. 

Anatomical Characters. — In the most common form of bronchitis, 
the larger bronchial tubes only are aff^ected. They are the seat of the in- 
flammation in most of those cases which are designated " colds " by families, 
and which ax'e often treated witliout the aid of the physician. The lining 
membrane of the bronchial tubes presents the ordinary anatomical char- 
acters of mucous inflammations. It is reddened uniformly or in joatches, 

32 



498 BROXCHITIS. 

intensely, or in that milder degree known as arborescence, according to the 
severity of the inflammation. 

The secretion of the muciparous follicles is at first arrested, aud the sur- 
face of the membrane is dry. In the course of a day or two the secretory 
function is re-established, and the surface is covered with thin and trans- 
parent mucus. A day or two later, the secretion becomes thicker, consist- 
ing of mucus aud pus. Mixed with these substances are epithelial cells, 
which are exfoliated in abundance from the inflamed surface. At the 
same time the mucous membrane becomes thickened and more or less soft- 
ened. If the inflammation is severe, the vessels of the submucous connec- 
tive tissue are also injected. 

Usually, in about a week in the young child, in from one to two weeks 
in older children, the inflammation begins to abate. Gradually the in- 
flamed membrane returns to its normal consistence, thickness, and vascu- 
larity, and with this return to the healthy state the muco-purulent secre- 
tion abates. 

In this, which is the simplest form of bronchitis, and most common, 
there is no ulceration, and rarely any pseudo-membranous formation, if 
the disease is idiopathic. Pseudo-membranous bronchitis is not unusual 
as an accompaniment of pseudo-membranous laryngo-tracheitis. 

Were bronchitis limited to the larger bronchial tubes, it would indeed 
be a simple affection, but unfortunately it has a tendency to extend down- 
wards. Commencing in the larger, it gradually invades the smaller tubes 
in a similar manner to the extension of erysipelas upon the skin. More 
rarely the inflammation commences simultaneously in the larger aud 
smaller tubes. Kow the gravity of bronchitis is proportionate to the de- 
gree of its extension downwards. It may stop at auy point in its progress, 
but if it reach the smaller tubes it is one of the most serious aflTections of 
early life. 

The mucous membrane of the minute tubes, those next to the air-cells, 
is delicate, with but little submucous connective tissue, and it frequently, 
at post-mortem examinations, does not present to the eye those distinct in- 
flammatory changes which are observed in tubes of large diameter. It is 
sometimes not notably thickened, nor its vascularity much increased, even 
when there is reason to believe from the symptoms that it was the seat of 
active phlegmasia. As we pass from these minute tubes to those of larger 
calibre, the inflammatory lesions become more distinct. The iuflammation 
produces minute and abundant points of reduess, and the membrane is 
evidently thickened ; often it is rough or granular. 

The minute bronchial tubes are very small, especially under the age of 
three years, and since in capillary bronchitis a large proportion of them 
are inflamed, the source of the danger is apparent. It is with difficulty 
that the patient with capillary bronchitis can, by the effort of coughing, 
free the tubes from the secretions which are constantly collecting in them. 



ANATOMICAL CHARACTERS. 499 

In weakly children, under the age of two years, expectoration is most 
difficult, and hence the great and increasing dyspnoea from which such 
patients suffer. 

In severe and unfavorable cases of bronchitis, which are chiefly those 
in which the small as \Yell as large tubes are inflamed, the following an- 
atomical changes commonly occur : The muco-purulent secretion, which is 
tenacious, collects more rapidly in the smaller tubes than it is expectorated 
by the child, whose strength begins to be exhausted. The accumulation 
of the secretion is chiefly in the tubes which lie in the posterior and 
inferior portions of the lung. As the obstruction from the muco-pus 
increases in these tubes, less and less air passes through them into the 
alveoli with which they communicate, while the quantity of air which 
passes through the unobstructed tubes into the anterior and superior por- 
tions of the lung is proportionately increased. The effect, as regards the 
state of the lung, is obvious. In cases having a fatal issue, and in which 
we are therefore able to inspect the lesions, we find that the lower and 
inferior portions of the organ, from which air was to a greater or less 
extent excluded, have a diminished crepitation, that they lie a little below 
the general level, or that certain lobules do, and that they present a con- 
gested appearance, for while they contain too little air they have an excess 
of blood. We shall also find that the upper and anterior parts of the 
organ, perhaps the entire upper lobe, contain more than the normal quan- 
tity of air, so as to rise above the general level. There is distension of the 
alveoli in these parts, so that they are probably visible to the naked eye, 
and may appear to be emphysematous, but this is a state distinct from 
emphysema. It is merely an inflation of the alveoli to nearly their full 
capacity. 

Here and there, in the portion of lung in which the inflation has been 
incomplete, lobules may be observed which are entirely collapsed, having 
a dusky red color and no crepitation ; while in other parts, if the bronchitis 
has continued some days, there may be nodules of pneumonia. The incised 
surface of those portions of the lung to which the access of air has been 
prevented, whether they are collapsed fully, or partially, or not, has a 
reddish color from congestion, and is moist from serum and blood. On 
compressing the lung, the muco-purulent secretion appears upon the sur- 
face in points, having escaped from the divided ends of the tubes. For 
other facts relating to atelectasis, the reader is referred to the chapter in 
which this malady is described. 

In exceptional cases, a fibrinous exudation occurs in the bronchial 
tubes, in addition to the mucus and pus, forming a delicate film, observed 
here and there, and readily detached from the surface underneath. lu 
rare instances it occurs as a firm and continuous membrane, forming a 
mould of the tubes, increasing greatly the dyspnoea, and constituting a true 
bronchial croup. If the- patient with capillary bronchitis survive, the 



500 BROXCHITIS. 

inflammation of the mucous membrane soon begins to abate. The tubes 
which have been the seat of the disease, and the alveoli which have been 
secondarily involved, may return to their normal state almost immedi- 
ately; but in other instances such anatomical changes occur in them, even 
when there is no pneumonia, or complete collapse, that restoration to their 
normal state is necessarily somewhat slow. When the function of a lobule 
ceases, as it does when the tube leading to it is obstructed, not only hy- 
perjiemia occurs with or without collapse, as already stated, but its cells and 
nuclei, and perhaps other parts, begin to undergo fatty degeneration. These 
elements become granular, somewhat enlarged and opaque, and here and 
there mixed with them are other large cells filled with oil-globules. These 
are the compound granular cells of pathologists, and, occurring in this 
situation, are produced by metamorphoses of the epithelial cells. They 
are epithelial cells which have progressed more rapidly than others in fatty 
degeneration, having reached that stage of it which immediately precedes 
liquefaction. AVe often with the microscope observe not only these cor- 
puscles, but their fragments as they are dissolving. 

Minute abscesses, usually directly under the pleura, have occasionally 
been observed at the autopsies of those who have recently had capillary 
bronchitis, and pathologists are not agreed as to the mode in which they 
are produced. Some of them, if not all, are evidently connected with the 
minute bronchial tubes, and the quantity of pus contained in each is not 
usually more than one or two drops. The most reasonable view of their 
causation is that they are produced in the terminal tubes where the mucus 
and pus collect. The pus acts as an irritant and causes inflammation, and 
the inflammation increases the quantity of pus. The walls of the tube 
which is now the seat of an abscess are destroyed by ulceration, and prob- 
ably, also, some of the contiguous air-cells. The little cavity is soon sur- 
rounded by a delicate membrane, the same in character, though less thick 
and firm, with that which constitutes the walls of larger abscesses. The 
pus presents the usual appearance of this liquid, or it may be tinged by 
the presence of blood-cells, or again it may be thick from partial absorp- 
tion of the liquor puris so as to resemble softened tubercle. 

The abscess is ordinarily located in the centre of a collapsed lobule. In 
certain cases it approaches the surface of the lungs, so as to produce cir- 
cumscribed pleurisy, with adhesion of the costal and visceral pleura. At 
the autopsy of such a case, on separating the adhesions and attempting in- 
sufiiation, the air passes through the aperture, so that the lung on that side 
cannot be inflated unless the aperture is closed. Occasionally pneumo- 
thorax results from opening of the abscess into the pleural cavity. 

In severe protracted bronchitis dilatation of certain of the bronchial tubes 
sometimes results. The alveoli in the upper lobes may also be distended 
beyond their physiological capacity, so as to produce emphysema, but as 
we have stated above, their maximum distension within physiological limits, 



SYMPTOMS. 501 

must not be mistaken for emphysema. Emphysema in the upper lobes is 
common in feeble young children, with relaxed and weakened tissues, oc- 
curring even without any severe disease of the respiratory organs. It may 
be vesicular or interstitial. If it is interstitial the sacs of air often attain 
considerable size, lying as wedges between the alveoli, or like little blad- 
ders upon the surface of the lung. It is not difficult to understand how 
emphysema occurs in capillary bronchitis, since the air partly arrested in 
the tubes leading to the lower lobes enters the upper lobes in greater vol- 
ume and force. 

Symptoms. — It is evident, from the description which has been given of 
the anatomical characters of bronchitis, that its symptoms vary greatly in 
severity in different patients. It usually commences with more or less 
coryza. The symptoms are headache, flushed face, elevation of tempera- 
ture, acceleration and fulness of pulse. In the mildest cases these symp- 
toms are scarcely appreciable. The child is observed to sneeze and have 
some defluxion from the nostrils, and this is followed by an occasional 
mild, almost painless, cough, which declines in the course of a few days. 
The respiration and pulse are scarcely accelerated, and the appetite is but 
slightly impaired. There may be a little fretfulness, but the child is not 
confined to his bed or room, and usually amuses himself with his playthings. 
Auscultation in these mild cases reveals coarse mucous rales in the larger 
bronchial tubes, while the smaller tubes are free from mucus. Sibilant and 
sonorous rales are also observed, especially in the commencement of the 
bronchitis, at which time the secretion of mucus is suppressed or scanty. 
The cough in the commencement is for the same reason dry. It becomes 
looser by the second or third day, the sputum consisting of frothy mucus, 
with the admixture of pus and epithelial cells. The pus becomes more 
abundant as the disease continues. Expectoration* does not usually occur 
till after the age of four or five years ; under this age the sputum is ordi- 
narily swallowed. 

The mild form of bronchitis described above, that in which only the 
larger bronchial tubes are aflfected, is common at all periods of infancy and 
childhood, but a severer grade of the disease is also of common occurrence, 
exclusive of those cases in which the minute branches of the bronchial tree 
are affected. It has already been stated that there is a tendency in bron- 
chial inflammation to extend downwards, and symptoms are proportionate 
in gravity to the degree of this extension. In severe bronchitis the pulse 
rises to 120 or 130 per minute, and the respiration is in a corresponding 
degree accelerated. The cough is frequent and painful, the pain being 
referred to the sternum, and often there is a steady dull pain inthis region. 
The face is flushed aud indicative of suffering, the temperature is consider- 
ably elevated, and the appetite is greatly impaired or lost. There is fre- 
quently an exacerbation of symptoms in the latter part of the day. De- 



502 BROXCHITIS. 

pression of the infra-mammary region during inspiration, and dilatation of 
the alve nasi, accompany grave attacks of the inflammation. 

Auscultation in severe bronchitis reveals the presence of rales in all 
parts of the chest, sibilant and sonorous sparingly, coarse mucous and sub- 
crepitant more abundantly. 

Capillary bronchitis or suffocative catarrh, the most dangerous form of 
this inflammation, is less frequent than bronchitis, which is limited to the 
larger tubes, or to the larger tubes and those of medium size. It may com- 
mence quite abruptly, but ordinarily it results from the milder form of the 
disea.se. The symptoms at first are such as occur in the common form of 
bronchial inflammation, but instead of abating or remaining stationary, 
they gradually increase in .severity till, suddenly, marked dy.spnoea super- 
venes. The inflammation has now reached the minute tubes, and what 
promised to be an ordinary attack of bronchitis becomes one of great 
severity and danger. 

The respiration in capillary bronchitis is .short and harried. Sixty to 
eighty inspirations per minute are not infrequent, while the pulse also is 
greatly accelerated, attaining as high a number as 140 to 160 or 180 beats 
per minute. The cough is frequent, and the sputum, which collects in 
abundance, is expectorated with difficulty. If expectorated .so as to be 
examined, it is found to consist largely of frothy mucus with epithelial 
cells. After a few days, if the patient live, it becomes more purulent. 
Sometimes, as in bronchitis of the adult, streaks of blood appear upon the 
mucus. In the first days of capillary bronchitis, the temperature is con- 
siderably elevated, the face flushed and indicative of suffering. The patient 
is restless, moving from one part of the bed to another, seeking in vain 
for relief. The digestive function is impaired, as in all severe inflamma- 
tions ; the tongue is moist and covered with a light fur ; the appetite is 
nearly or quite lost. The nur.sing infant nurses with diflSculty, frequently 
relinquishing the breast on account of the dyspnoea; older children take 
no solid food in con.sequence of the anorexia and the dyspnoea, and even 
drinks are swallowed hastily and apparently without relish, since degluti- 
tion interferes with respiration. On au.scultation in capillary bronchitis, 
at first sibilant, and after a day or two subcrepitant, rales are observed in 
every part of the chest. Percussion elicits a good resonance, unless the 
substance of the lung has become involved. As the disease approaches a 
fatal termination; the pulse becomes greatly accelerated, the respiration is 
also in a corresponding degree frequent and panting, the inspiration being 
accompanied by marked infra-mammary depression and dilatation of the 
alse nasi. The face becomes pallid, the prolabia livid, and the tips of the 
fingers livid and cool. The mucus and pus, accumulating in the air-pas- 
sages, increase more and more the ob.struction to the entrance of air, and, 
finally, death occurs from apnoea. The nursing infant usually ceases to 
nurse for several hours before death, and a .state of stupor commonly pre- 



SYMPTOMS. 503 

cedes the fatal event, clue to the accumulation of carbonic acid iu the blood. 
In young infants, especially those under the age of six months, not only 
in capillary bronchitis, but in severe ordinary bronchitis, I have often 
observed, toward the close of life, intermissions in the respiration. It 
occurs after every six or eight or ten respirations, and equals in duration 
the time occupied in, perhaps, half a dozen respiratory movements. It is, 
therefore, an unfavoi'able prognostic, but some recover by stimulation in 
whom it occurs. 

The duration of acute bronchitis varies according to the extent of the 
inflammation. In the mildest form, the patient is convalescent after three 
or four days, and, in severer forms that terminate favorably, the disease 
begins, ordinarily, to decline by the close of the first week or in the second. 
The pi-ogress of bronchitis is somewhat more rapid in young children than 
in those of a more advanced age. When convalescence is fully established, 
it is not unusual for the cough to continue three or four weeks, though 
gradually declining. It is loose and painless, and is scarcely regarded by 
the patient. 

Death sometimes occurs as early as the second or third day in capillary 
bronchitis. The younger the infont, with the same extent and intensity 
of inflammation, of course the sooner the fatal result. The ordinary dura- 
tion of fatal bronchitis is from six to eight days. If the patient pass beyond 
the tenth day, decline of the inflammation may be confidently expected, 
and recovery, unless there is a complication. 

Occasionally bronchitis becomes chronic, lasting several months before 
it entirely ceases. The chronic form may result from mild, as well as severe, 
bronchitis. The active fever and accelerated respiration which charac- 
terize the acute affection abate, and the general health is nearly or quite 
restored ; but an occasional cough continues, and the respiration is often 
audible, from the mucus which collects in the tubes, or from thickening of 
the mucous membrane. Sometimes there is moderate febrile movement, 
especially in the latter part of the day. On auscultation, coarse mucous, 
with perhaps sibilant and sonorous, rales are observed in the chest. 

There is great liability in chr"onic bronchitis to exacerbations. The dis- 
ease often seems to be abating, and there is prospect of its speedy cure, 
when all the symptoms are intensified. The exacerbations are due to the 
fact that the bronchial surface, when it has been a considerable time 
inflamed, is very sensitive to the impression of cold. Even when the dis- 
ease is entirely relieved, it is very apt to return by exposure to currents of 
air or changes of temperature. Chronic bronchitis occurs most frequently 
in the winter and in the spring and fall, when the weather is changeable, 
and is most intractable in these periods of the year. Many cases of 
chronic bronchitis are associated with dilatation of the bronchial tubes or 
with emphysema. The general health in chronic bronchitis, when not 
dependent on a tubercular deposit, ordinarily remains good. Tubercular 



504 BRONCHITIS. 

brouchitis, which is the result of a grave disease, does not require a sepa- 
rate consideratioD. It is attended with emaciation, and is obstinate on 
account of the nature of the primary affection. It is due to the irritating 
effect of tubercular matter lying against the bronchial tubes. 

DtAGXOsrs. — Bronchitis can ordinarily be diagnosticated by the char- 
acter of the respiration and cough. The absence of hoarseness, stridulous 
inspiration, and croupy cough, excludes laryngitis; and the absence of 
the expiratory moan and of the stitchlike pain on coughing, which char- 
acterize pneumonia and pleurisy, excludes those diseases. Accurate diag- 
nosis, however, can be most readily made by percussion and auscultation. 
Examination of the chest enables us to state with positiveuess, not only 
the nature, but the extent of the affection. If the inflammation is con- 
fined to the larger bronchial tubes, coarse rales are discovered in them, 
while finer mucous rales are absent. If the bronchitis is capillary, sub- 
crepitant rales are discovered in the smaller tubes. Percussion gives clear 
resonance on both sides, except in those instances in which collapse or 
j^neumonia has supervened. 

PROGNasis. — Bronchitis, limited to the larger bronchial tubes, or to 
these and those of medium size, terminates favorably in a large majority 
of cases. Occasionally, severe inflammation, not extending to the smaller 
tubes, proves fatal in young infants, or those of feeble constitution. True 
capillary bronchitis is, on the other hand, a disease of great danger. It 
may be fatal at any period of childhood, but the younger the patients and 
more feeble, the greater the proportion of deaths. Under the age of one 
year, it is one of the most fatal diseases of early life. 

The prognosis, in the commencement of all cases of bronchitis of aver- 
age severity in the young child, should be guarded, on account of the 
tendency of the inflammation to extend, since ordinary bronchitis may 
become capillary. After five or six days extension ceases, and, if during 
that time there is no increase in the severity of symptoms, the prognosis 
is favorable. Signs which indicate an unfavorable result are increasing 
frequency of pulse and respiration, difficult and scanty expectoration, 
restlessness, a countenance indicative of suffering, and a progressively 
greater accumulation of mucus in the bronchial tubes, as determined by 
auscultation. Pallor and coldness of the face and extremities, lividity of 
the tips of the fingers, rapid and feeble pulse, drowsiness, diminution of 
cough, while the mucus and pus accumulate in the bronchial tubes, and, 
in young children, intermissions in the respiration, indicate the near ap- 
proach of death. Cases may, however, recover by proper treatment, 
although the symptoms are most unfavorable. 

It is unnecessary to mention the favorable prognostic signs of bronchitis. 
This disease, when fully established, continues a certain number of days, 
whatever remedial measures are employed, and, if the symptoms do not 
increase in severity during the first five or six days, a favorable result is 



TREATMENT. 505 

highly probable. The prognosis in chronic bronchitis is ordinarily favor- 
able, so far as life is concerned, provided there is no emaciation. If there 
is emaciation, the bronchial inflammation may be due to tubercles in the 
bronchial glands or lungs, and, of course, the prognosis is unfavorable. 

Treatment. — Bi'onchitis may be rendered much milder, and perhaps 
even prevented, by an emetic employed in the first twelve or twenty-four 
hours, in conjunction with a warm bath. The physician is not, however, 
ordinarily called sufficiently early to render this treatment effectual. The 
remedial measures proper for this disease vary greatly, according to the 
stage and intensity or extent of the inflammation and the age of the 
patient. Bronchitis, limited to the Imager tubes, requires simple measures. 
A laxative may be employed, with a mild expectorant, and moderate 
counter-irritation should be produced by camphorated oil, or the occa- 
sional employment of a sinapism. I have sometimes ordered for these 
cases a mixture recommended by Dr. James Jackson, of Boston, in his 
letters to a young physician. " For young children," .... says he, " I 
employ the following : Take of either almond or olive oil, of syrup of 
squills, of any agreeable syrup, and of mucilage of gum acacia, equal 
parts, and mix them. Of this mixture, a teaspoonful may be given to a 
child at two years of age ; a little less if younger, and increased if older, 
so as to double the dose to one in the sixth year. This may be given 
from three to six times in the twenty-four hours. Sometimeis a little 
opiate must be added at night to appease an urgent cough." These cases 
also do well with simple mucilaginous drinks in conjunction with gentle 
aperients. 

Bronchitis, extending beyond the primary or secondary bronchial divi- 
sions, requires more careful watching and more decided met^sures. The 
abstraction of blood by leeches, or otherwise, is seldom required in the 
treatment of bronchitis. Occasionally, if the inflammation is intense and 
the symptoms urgent, moderate abstraction of blood at an early period 
may be useful, but the employment of cardiac sedatives under such cir- 
cumstances is generally preferable. 

As a rule, actively depressing agents should be avoided in the treatment 
of bronchitis in patients under the age of two years ; and, on the other 
hand, sustaining remedies are in a large proportion of cases required after 
the first two or three days. Many infants with bronchitis are sacrificed in 
consequence of the old theory, which still influences medical practice, that 
an inflammation, with its increased force of circulation, is necessarily best 
controlled by depletory and sedative measures. Remedies too depressing 
are prescribed, and with a less favorable result than would follow a strictly 
expectant course of treatment. 

What is, therefore, the proper mode of treating bronchitis, severe or of 
ordinary gravity, occurring in infancy and childliood ? It is supposed that 
the physician is called when the inflammation is fully established, or that, 



506 BRONCHITIS. 

if he has seen the patient at the commencement, and has prescribed an 
emetic, it has failed to throw off the disease. A large emollient poultice, 
not thicker than the cover of a book, so wet as to produce constant mois- 
ture of the surface, and sufficiently irritating to produce constant I'edness 
without necessitating its removal, should be applied to the front and sides 
of the chest, and over it an oil-silk jacket placed. I prefer a poultice of 

the following : 

R. Pulv. sinapis, ^ss. 

Pulv. semin. liiii, 5viij. Misce. 

Local treatment in bronchitis is very important. The exact mode of 
applying it, or the substances used, matters little, provided that it meets the 
indication, which is twofold, — namely, derivation to the surface, and the 
aiiplicatiou to it of warmth and moisture. Such applications are found, 
by experience, to give most relief Warmth and moisture are furnished 
by cataplasms most conveniently, or by warm water applications under 
oil-silk. 

Derivation to the surface, early made and repeated, tends to check the 
downward extension of bronchitis ; but it is not advisable to vesicate, or to 
produce anything more than moderate and continued redness. Often im- 
pi'ovement in symptoms is observed, especially less dyspnoea and restless- 
ness, immediately on the employment of the local measures recommended 
above. If the bronchitis have that severity that there is a decided febrile 
movement, accelerated respiration or pain on coughing, this external treat- 
ment should in my opinion always be employed, but if the disease is so 
mild that these symptoms are absent the case will probably do well with- 
out it. The internal treatment appropriate for bronchitis varies accord- 
ing to the age of the patient and the character of the inflammation, 
whether it be primary or secondaiy. The following formula3 will be found 

useful : 

R. Amnion, carbonat., gr. v. 

Syr. bal. tolut. , ^ss. 

Aquae, 3iss. Misce. 

Dose, one teaspoonful every two or three hours for an infant of three months. 

Infants of this age usually require also alcoholic stimulants, as six or 
eight drops of brandy every two or three hours. 

R. Spts. aether, nitr., ^j. 
Syr. ipecacuanhse. 
01. ricini., aa ,^ij. 
Syr. bal. tolut., ^vij. Misce. 
Dose, one teaspoonful every two to four hours to an infant one year old with 
acute primary bronchitis. 

R. Syr. ipecacuanha3, gij. 
Potas. acetat., gr. xvi-^ss. 
Syr. simplicis, ^xiv. Misce. 
Dose, one teaspoonful to an infant of six months with acute primary bronchitis. 



TREATMENT. 507 

Medicines which exert a greater controlling effect upon the action of 
the heart than those which we have mentioned, are often required in the 
first days of severe bronchitis, namely, in those cases in which the patient 
is robust, while the pulse is unusually rapid and temperature elevated. 
One or two drops of tincture of digitalis may be added to each dose of the 
prescription for an infant between the ages of six months and two years. 
For children over the age of two yeai's, whose previous health has been 
good, aconite is preferable as a cardiac sedative. The following will be 
found a useful recipe for a child of five years : 

R. Tinct. rad. aconit., gtt. xvj. 
Syr. scillse composit., ^ij. 
Syr. bal. tolut., ^xiv. Misce. 
Dose, one teaspoonful from two to four hours. 

The medicine to be omitted or given at a longer interval if the frequency 
of the pulse is reduced. I have nearly abandoned the use of veratrum 
viride for the bronchitis of childi-en on account of its very depressing effect. 
If there is restlessness, Dover's powder, paregoric or syrup of poppy 
should be administered with the expectorant mixture or separately. 
Squibb's liquid Dover's powder, the tinct. ipecac, comp., is a useful and 
convenient remedy to procure sleep in these cases. It may be given to an 
infant of one year in one-drop doses. Agents more depressing than ipecac- 
uanha should not be administered to infants under the age of six months, 
even in the commencement of acute bronchitis. 

The effect of the stronger cardiac sedatives, as aconite and veratrum 
viride, in the bronchitis of children, should be carefully watched. In gen- 
eral they should be administered only during the first three to five days; 
but if the child is robust, with full and strong pulse, they may be con- 
tinued longer. In many cases of primary and secondary bronchitis during 
its active period, quinine, administered in large doses, is an invaluable 
remedy, as a substitute for digitalis, aconite or veratrum viride. Like 
those agents it diminishes the temperature and the frequency of pulse, 
while it acts as a general tonic and preserves the strength of the heart's 
contractions. This effect of quinine, which has only in recent years been 
brought prominently to the notice of the profession, and is now accepted 
as a valuable fact in therapeutics, indicates an important use for this agent 
in several of the most common and severe diseases of children, as bron- 
chitis, pneumonitis, scarlatina, and diphtheria. While it may not reduce 
the frequency of the pulse as quickly as aconite, or to the same extent, it 
has in my practice been equally effectual iu reducing the temperature. As 
many as six or eight grains may be administered daily in divided doses to 
a child of two or three years. If this agent is properly administered, and 
the dose reduced as the fever abates, cinchonism, at least so as to be in- 
jurious, seldom occurs. As the active inflammation begins to abate, simple 



508 BRONCHITIS. 

expectorant mixtures may be given, as syrup of squills or ipecacuanha in 
spiritus Mindereri. At this stage of bronchitis, it is often best to com- 
mence the use of stimulating expectorants, and they are required in nearly 
all cases of advanced bronchitis. In secondary forms of the disease, as 
when it occurs in connection with hooping-cough or measles, such expect- 
orants should be employed from the first ; and also, if there is a state of 
feebleness or cachexia, although the bronchitis is primary. It is important 
for successful practice to be able to determine at what period in the disease 
this class of medicinal agents should be prescribed. In doubtful cases it 
is safer to prescribe them than those of a depressing character ; but it is 
better to employ, for a day or two, a simple mucilagiuous or other soothing 
mixture, after which a stimulating expectorant can be given. When 
quinine is employed, the use of these expectorants may be deferred or 
dispensed with. A favorite prescription with me is the following : 

R. Amnion, carbonat., gr. xvj-xxiv. 
Tinct. sanguinar., gtt. xxiv. 
Syr. senegje, ^ij. 
Ext. glycyr., ^ss. 
Aqufe, .^xiv. Misce. 
Dose, one toaspoonful every two or three hours to a child of two years. 

As convalescence approaches, the medicine should be administered less 
and less frequently, or in smaller doses. Emetics in ordinary cases of 
bronchitis are not required, except in the commencement. In severe bron- 
chitis, however, especially when the smaller tubes are inflamed, they are 
sometimes of great service. The cases which require their administration 
are those in which mucus and pus collect in the tubes more rapidly than 
they are expectorated, so as to give rise to urgent dyspnoea. Nothing gives 
such decided and immediate relief under these circumstances as an emetic. 
The object to be gained is obviously very different from that in the com- 
mencement of bronchitis, and such agents should be employed as act 
promptly, with the least possible depression. Sulphate of zinc or of copper 
is, therefore, an appropriate medicine. The former may be given in a dose 
of five grains ; the latter, of one or two grains to a child five years old. 
If there is considerable strength of pulse and heat and dryness of surface, 
ipecacuanha may be administered. If there are evidences of exhaustion, 
stimulants may be administered immediately before and after emesis. 
Infants oppressed by the accumulation of mucus and pus may sometimes 
be relieved by tickling the fauces with the finger. This provokes vomiting, 
and the viscid mucus which collects at the entrance of the glottis is removed 
by the finger. 

In secondary bronchitis whatever the age, in primary or secondary 
occurring in infants or feeble children, the diet should, as a rule, be nutri- 
tious through the entire disease. Robust patients, or those who have had 



ATELECTASIS. 509 

ordinary health, if over the age of two years, and affected with pri- 
mary bronchitis, should have light diet, chiefly farinaceous, in the first 
days of the attack, after which animal broths are proper. Whatever food 
is given in severe bronchitis must be in the form of drinks, since the ap- 
petite is lost, while the thirst is such that liquids are less likely to be 
refused. 

In primary bronchitis, if mild or of oi'dinary severity, alcoholic stimu- 
lants are not required. In secondary bronchitis they are often needed, 
and also in capillary or severe ordinary bronchitis, if there is dyspnoea 
with evidences of prostration. The occasional loose cough which is often 
present during the period of convalescence requires but little treatment; 
either no medicine or a gently stimulating expectorant may be given. 



CHAPTEE V. 

ATELECTASIS. 

In certain new-born infants the lungs do not undergo inflation, or only 
a portion of the lobules are inflated, to wit, those in the upper lobes, while 
the remainder of the organ continues unchanged from the foetal state. 
This non-inflation of the lung is designated congenital atelectasis. It is 
not due, unless in rare instances, to any defect or vice in the respiratory 
apparatus, for at the autopsies of cases which have ended fatally, as most 
cases do, at an early period, insufflation is easy, there being no occlusion 
of the air-passages, nor unusual adhesion of the walls of the alveoli to pre- 
vent the admission of air. Physicians have believed that in some instances 
they discovered the cause in an enlarged thymus gland, which compressed 
the lower part of the trachea, but this cause, in my opinion, does not exist 
or is exceptional, for although the thymus at birth is large, having nearly 
the size of an unexpanded lung, it has not seemed to me to be unduly en- 
larged in most atelectatic cases which I have examined after death. 

The ordinary proximate cause of atelectasis neonatorum is feebleness of 
inspiration, whether due to general debility, as in infants born prematurely, 
or weakened by placental haemorrhage in the last months of fretal life, or, 
as is frequently the case, to injury of the brain and consequent impairment 
of the function of the pneumogastrics during birth. I have more fully 
treated of this form of atelectasis in the chapters which relate to the mal- 
adies incidental to the birth of the child, and to these the reader is referred. 

Acquired Atelectasis, or collapse of lung, is less extensive than con- 
genital atelectasis, being confined to a portion of a lobe, and often to only 



510 ATELECTASIS. 

a few lobules. It occurs chiefly during the period of infancy and in feeble 
children. It is a common malady, in f6uudling asylums, in wasted infants 
who perish before the close of the first year. I have frequently at the 
autopsies of such infants observed it along the thin inferior margins of the 
lower lobes, and in the tongue-like prolongation of the left upper lobe. In 
this class of cases, catarrh of the bronchial tubes appears to have little or 
no agency in causing the collapse. The cause is found in the impaired 
functional activity of the lungs. In the state of debility the heart beats 
feebly and the stream of blood from it to the lungs is small and slow, so 
that the inspiration of a small amount of air suffices for its decarboniza- 
tion. The inspirations also are seen to be feeble, causing little expansion 
of the walls of the thorax. Consequently the entire lung is imperfectly 
inflated, as is seen in fatal cases, but the distant thin portions of the organ 
are least expanded. These receiving little or no air, soon begin to contract 
from the presence of the elastic tissue, and collapse or atelectasis ensues. 

This has been the most common form of atelectasis in cases of this 
malady, which I have observed in foundling asylums, and it probably 
occurred in the manner which I have described. 

Another cause of acquired atelectasis to which all writers allude is bron- 
chial catarrh, which commencing in the larger tubes extends downwards 
into those of smallest size. By the swelling of the mucous membrane, and 
the accumulation of viscid muco-pus which cannot be expectorated, cei'- 
tain of these tubules become occluded, so that the inspired air is shut ofi" 
from the alveoli situated beyond them. Occlusions are obviously most apt 
to occur in the bronchitis of feeble infants, whose cough has little expul- 
sive force, so that debility is also a factor in the production of this form of 
atelectasis. The portion of lung withdrawn from the respiratory function 
soon collapses, the air which it contained being probably in part expired, 
but chiefly absorbed. 

Atelectasis is not, however, so important or frequent a complication of 
bronchitis as was formerly supposed, for catarrhal pneumonitis due to ex- 
tension of the inflammation from the bronchioles into the lung has been 
mistaken for it. Solid uou-crepitant nodules or portions of lung are fre- 
quently observed at the autopsies of infants who have perished of severe 
bronchitis, and these may be atelectatic or pneumonic, but they have in 
my observations been more frequently the latter than the former. 

The possibility of insufflating these solid portions when removed from 
the body after death, was till within a few years regarded as the decisive 
proof of atelectasis. But this is now known to be no test, since a lung 
solidified by recent catarrhal pneumonitis can be almost as readily inflated 
as that which is collapsed. Nevertheless, the inflated pneumonic lung is 
more solid and resisting when pressed between the thumb and fingers than 
is the collapsed lung. The decisive proof is afforded by the microscope, 
by which cell-proliferation is discovered within the alveoli in catarrhal 



ANATOMICAL CHARACTERS. 511 

pneumouitis, while it is lacking in simple collapse. An increase of the 
dyspnoea not infrequently occurs in severe infantile bronchitis, without 
either pneumonia or collapse from the accumulation in the bronchioles of 
the secretion which is with difRculty expectorated, but if dulness on per- 
cussion and other physical signs indicate solidification of the lung at some 
point, of course pneumonia or collapse has occurred. If a sufficient 
amount of lung is involved to produce well-marked physical signs the dis- 
ease is in most instances pneumonia and not collapse, though it may be the 
latter. Both these pathological states may, however, occur in the same lung 
as complications of severe bronchitis. The severe paroxysmal cough of 
pertussis, especially when accompanied by considerable secretion, is apt to 
produce collapse of portions of the lower lobes, while it causes emphysema 
in the upper lobes. 

Symptoms. — Atelectasis resulting from bronchitis gives rise to no new 
symptoms, but so far as it has any appreciable effect it aggravates certain 
symptoms of the primary disease, but as it is ordinarily limited to a small 
area this effect is not very marked. When a bronchial tube is so occluded 
by muco-pus that the alveoli with which it communicates, collapse, there 
is ordinarily, at the same time, more or less accumulation of this secretion 
in other tubes throughout the lungs. Therefore, the entrance of air into 
the alveoli with which these tubes communicate is slow and difficult, but 
usually without complete obstruction, and without true atelectasis, but 
with a semi-collapse such as we observe in fatal croup. This explains the 
dyspnoea which is present in these cases. If the secretion is expectorated 
from these tubes the dyspnoea abates, even if the plug which has completely 
occluded a tube, and the consequent atelectasis remain. 

Atelectasis occurring in wasted and feeble infants, in consequence of the 
diminished force of the inspirations, does not in most instances give rise 
to any prominent symptom, since it occurs chiefly in distant thin portions 
of the lungs. I have observed an occasional short, nearly paiul&ss cough 
in such infants, when the autopsy revealed no pulmonary lesion except the 
atelectasis. 

Anatomical Characters. — The portion of lung which is affected with 
recent atelectasis, has a dark-brown or dark-bluish color. It is depressed 
below the general level of the lung,*is firm and non-crepitant on pressure, 
and its incised surface is smooth. Hypersemia supervenes for a portion 
of lung in which the circulation continues, but from which air is excluded 
becomes congested. In acquired atelectasis the congestion is especially 
marked, since the vessels which have been adapted by growth for a larger 
area, are compressed into one of smaller extent, so that they become 
tortuous and bulging within the lumina of the alveoli, while the free flow 
of blood through them is retarded by the constriction of the elastic fibres 
of the lung. An obvious and certain result of the hyperreraia is the 
trausudation of serum into the alveoli, producing oedema. This union of 



512 ATELECTASIS. 

pulmonary hyperiemia with oedema by which air is excluded from the 
alveoli constitutes the state known to pathologists as splenization, and in 
proportion as it occurs, the lung depressed by the atelectasis rises towards 
the general level. It may even rise above it, and it now has a doughy 
elastic feel. The pathology of these oederaatous atelectatic spots, heretofore 
obscure, has been clearly explained by Rindfleisch. 

If the patient live, and the atelectatic lobules do not soon return to a 
state of health, they undergo further changes. Rindfleisch says: "From 
the series" (of changes, provided inflammatiou do not occur), "we especially 
render prominent two conditions, inveterate oedema, and slaty induration. 
But inflammation does commonly occur after a time in a collapsed lung." 
Those who are familiar with the post-mortem examinations of infants will 
fully agree with Rindfleisch when he says: "Splenization, quite generally 
taken, appears to present extraordinarily favorable preliminary conditions 
for the occurrence of inflammatory changes. It may directly represent the 
initial hyperpemia of acute inflammation, and be followed by lobular and 
lobar, but constantly catarrhal infiltrates." It is well known by pathol- 
ogists that protracted congestion, active or passive, of whatever organ or 
tissue, is very apt to pass from a state of simple stasis of blood to one of 
cell-proliferation, and the atelectatic lung, as I have myself observed at 
autopsies, affords a common example of this. I have several times made 
or have procured microscopic examinations of the atelectatic portions of 
lungs of infants, who had died, for the most part, in a wasted and en- 
feebled state, and have fouud in them clear evidence of the presence of a 
catarrhal pneumonia. The interesting fact, therefore, must be recognized, 
that atelectasis frequently passes to a state of inflammation, so as to pre- 
sent the characters of ordinary hypostatic pneumonia, and no doubt undergo 
the same subsequent changes. 

Atelectasis, when recent and simple or uncomplicated, may soon disap- 
pear by the expectoration of the obstructing secretion, if such is present, 
or if there is no obstruction, by increased force of inspiration. If it do not 
soon disappear it undergoes one of the ulterior changes alluded to above, 
and henceforth the symptoms and history are those of the new malady 
■which has supervened. 

Treatment. — The treatment of acquired atelectasis is simple. If it is 
recent and there is evidence that it is due to the accumulatiou of the 
secretion in the bronchial tubes, an emetic, which acts promptly and with 
the least possible depression, may be very useful. It is especially indicated 
if there is little or no pneumonia, the strength not greatly reduced, and 
there is dyspnea with insufficient decarbonizatiou of blood in consequence 
of the abundance of the secretion in the smaller tubes. An emetic which 
acts promptly and with little prostration, may aid greatly in establishing 
the respiratory function in collapsed lobules, by expelling the obstruction, 
and producing a freer and deeper inspiration. One of the best if not the 



PNEUMONITIS. 513 

best emetic for this purpose is sulphate of copper, given in a dose of one 
to two grains to a child of one year. With or without the use of the 
emetic our main reliance must be on sustaining and stimulating measures, 
by which the cough, the cry, and the inspirations acquire more volume 
and force. Most cases require alcoholic stimulants and carbonate of am- 
monia. Rubefacient applications to the chest are also commonly employed, 
and are probably useful. 



CHAPTER VI. 

PNEUMONITIS. 

In children over the age of three years, pneumonitis differs but little in 
form or phenomena from that of the adult, being ordinarily primary 
except as it depends on an irritant, as tubercles, and extending rapidly 
over one or more entire lobes. In those under the age of three years it 
is, on the other hand, as a rule, a secondary affection, and limited to a 
part of a lobe. Most writers, until recently, have classified cases according 
to their origin as primary and secondary, or their extent as lobar and 
lobular, or their duration as acute or chronic. A better classification, 
having an anatomical basis, is that into catarrhal, croupous, and interstitial. 

Catarrhal pneumonitis consists in an inflammation of the air-cells, with 
an abundant proliferation of epithelial cells within them, and the exuda- 
tion of serum, but not of fibrin. The secondary and lobular pneumonitis 
of young children, alluded to above, is usually of this character. Croupous 
pneumonitis consists also in an inflammation of the alveoli, but with an 
abundant formation of pus-cells within them, and the exudation of fibrin 
and serum. The lobar and primary pneumonitis of advanced children 
and adults is commonly of this character. In both catarrhal and croupous 
pneumonitis, therefore, the solidification of the lung and exclusion of air 
are due mainly to the newly formed cellular elements with which the 
alveoli are filled, though the source and nature of these cells differ in the 
two diseases. Interstitial pneumonitis consists in an inflammation and 
hyperjDlasia of the connective tissue of the lungs. It is the chronic pneu- 
monia of authors, resembling in many respects, in its anatomical and 
clinical characters, cirrhosis of the liver. The inflammation which pro- 
duces this result is subacute, and in nearly all cases is dependent on some 
persistent local disease in the minute bronchial tubes or lungs, as softened 
or cheesy tubercles, cancer, abscesses, protracted inflammation of the 
alveoli or bronchioles, whether produced by the inhalation of dust of an 
irritating nature or other cause. Interstitial pneumonia is much more 
rare in children than adults, and, as it presents no peculiar features in 
them, it need only be alluded to in this connection. 



514 PNEUMONITIS. 

Causes. — Croupous pneumonitis in most cases results from that common 
cause of inflammations — namely, taking cold. It commences as a primary- 
disease within a few hours after exposure. Catarrhal pneumonitis, in ex- 
ceptional instances, also commences abruptly as a primary disease from the 
same cause, but being, probably in nine cases out often, secondary, it com- 
monly results from antecedent pathological states, which we will enumerate. 

First. Many cases result from bi'onchitis. The inflammation extending 
downward engages the minute bronchial tubes, and from them traverses 
the alveoli of one or more lobules. This is the broncho-pneumonia of chil- 
dren described by authors ; it occurs most frequently between the ages of 
six and eighteen months. 

Secondly. Hypostasis, or passive congestion, is an important factor in 
the causation of many cases, and in feeble infants it is not infrequently the 
sole cause. Infants with feeble health and languid circulation, lying in 
their cribs day after day with little movement of the body, are very liable 
to passive congestion of the depending portions of their lungs, and this by 
and by eventuates in a cell proliferation within the alveoli — in other words, 
a pneumonia presenting some peculiarities, but of the catarrhal form. In 
foundling hospitals, where feeble infants are received and treated, this is 
one of the most frequent pathological states, and is the prevailing form of 
pulmonary inflammation. It is sometimes described as hypostatic pneu- 
monia. Hence physicians, whose observations have been largely in such 
institutions, have almost ignored any other form of pneumonia in infants. 
Billard, a close and accurate observer, wrote nearly half a century ago : 
" Pneumonia of infancy presents peculiar characters, in which it differs 
from the same afiectiou in adults. Instead of being an idiopathic affection 
arising from irritation developed in the pulmonary tissue under the influ- 
ence of atmospheric causes, which often excite the disease, the pneumonia 
of young infants is evidently the result of a stagnation of blood in their 
lungs. Under these circumstances this blood may be regarded as a kind 

of foreign body It would, therefore, appear that inflammation of 

the lungs, which produces hepatization, arises in infants, in general, from 
some mechanical or physical cause." Valleix also states that he found the 
lesions of pneumonia in a majority of the infants who died in the Hopital 
des Eufants Trouves. The statements of Valleix are applicable also to 
the Infants' Hospital, and Nursery and Child's Hospital, of this city, as re- 
gards those cases in which death results from chronic disease. We shall see 
hereafter that hypostatic pneumonia is one of the most common complica- 
tions of chronic infantile entero-colitis, the summer complaint of the cities. 

Thirdly. Catarrhal pneumonia of infants sometimes results from collapse. 
It is not unusual to find, at the autopsies of infants who have died in a 
state of emaciation and feebleness, portions of the lungs remote from the 
bronchi collapsed, as, for example, the thin edges of the inferior lobes, and 
the tongue-like process of the upper lobe, the process which lies over the 



CAUSES. 515 

heart. The immediate cause of the collapse has been a bronchitis, or it 
has resulted directly from the general weakness of the infant, and its feeble 
respirations. Now, a collapsed lung soon becomes affected by passive con- 
gestion. The functional activity of an organ favors circulation through it, 
and if the function is abolished the flow of blood in the part is retarded, 
and stasis more or less complete results. The hypersemic state of collapsed 
pulmonary lobules presents the same anatomical condition, for the super- 
vention of pneumonia, as occurs in cases of hypostatic congestion. Con- 
sequently, cell proliferation soon begins in the collapsed alveoli, the vol- 
ume of the affected lung increases, and it becomes firmer and more resist- 
ing to the touch, and the microscope reveals the characters of a subacute 
but genuine catarrhal pneumonitis. I have made or have procured micro- 
scopic examinations of a considerable number of such specimens, and have 
found the alveoli more or less filled with cells of the epithelial character. 

In rare instances in infancy and childhood pneumonitis results, as it more 
frequently does in the adult, from an embolus detached from a clot, which 
had foi'med in some remote vein, in consequence of arrest of circulation in 
it, by inflammation of the contiguous tissues. This is described by writers 
as a distinct form of pneumonitis, designated embolic or embolismal. A 
specimen showing this mode of causation was exhibited by me at the New 
York Pathological Society, in February, 1868. An infant, born January 
22d, 1868, of strumous parents, had been fretful, but without appreciable 
ailment till February 3d, when inflammation of the connective tissue 
occurred on the anterior aspect of the left leg, a little below the knee. 
This extended downwards, suppurated, and the pus was evacuated Febru- 
ary 5th. In the meantime three other similar inflammations occurred, 
two on the right foot and leg, and the other over the parietes of the chest 
in the right infra-mammary region. Suppuration occurred in all of these. 

On February 8th this infant was suddenly seized with extreme dyspnoea, 
and died in a few hours. Numerous minute puriform collections (formerly 
called metastatic abscesses) were discovered in each lung, most of them 
scarcely larger than a pin's head. One of 
them on the right side in the middle lobe ■^^*^- ^^■ 

connecting with a bronchial tube had rup- 
tured into the pleural cavity, causing pneu- 
mothorax, collapse, and incipient pleuritis. 

The annexed figure exhibits the micro- 
scopic appearance of this softened fibrin, 
which, to the naked eye, so closely resem- 
bled pus. 

On account of the speedy death, the 
emboli had produced, in the lobules where 
they had lodged, little more than conges- 
tion or the first stage of pneumonitis around them. Had the infant lived 




516 PNEUMONITIS. 

longer, doubtless the ferments or the vibriones, whicli some consider the 
irritating element of emboli, would have produced suppurative inflam- 
mation. 

Anatomical Characters. — Nothing need be added in this connection 
to \vhat has already been said, in reference to interstitial and erabolismal 
pneumonias. Being comparatively rare in children, they present the 
same anatomical characters as in the adult. That unimportant form of 
pneumonia called pleurogenous, and which consists in a croupous inflam- 
mation of the superficial infundibula of the lung underneath an inflamed 
pleura, occurs in children as well as adults. Being secondary to the 
pleuritis, produced by extension of the inflammation of the pleura, it gives 
rise to no physical signs, or appreciable symptoms, on account of its slight 
extent, and as it presents no peculiar features in the child, it need only be 
alluded to. 

Croiqjous pneumonitis, which we have stated is the ordinary form of 
pulmonary inflammation in children over the age of five years, has the 
same anatomical characters as in the adult. It ordinarily involves an 
entire lobe. It is more frequent in the right than left lung, and in which- 
ever lung it occurs its most frequent seat is the lower lobe. The inflam- 
mation may, however, be limited to an upper lobe, especially on the right 
side. It ordinarily commences near the root of the lung and extends 
forward. 

Croupous pneumonitis presents three stages, that of congestion, red 
hepatization, and gray hepatization. In the stage of congestion the 
capillaries in the walls of the alveoli are greatly distended, bulging foi-- 
ward in loops within the alveolar spaces so as to diminish them, and a 
viscid albuminous fluid begins to exude, in which points of extravasated 
blood appeal'. The affected lung in this stage has a deep-red color, its 
elasticity is greatly diminished, and its density and weight increased. 
On account of the reduced size of the alveoli from the bulging of the 
alveolar walls, and the viscid fluid within the alveoli and terminal bron- 
chial tubes, the function of the affected lobe is nearly lost, and hence the 
dyspnoea which patients experience in the first stage of the inflammation. 

The second stage is characterized by the continued and increased escape 
of the liquor sanguinis and red and white corpuscles through the stigmata 
or little apertures which exist normally in the walls of the capillaries. 
The inflamed alveoli and the minute bronchial tubes which terminate in 
them are filled with this pneumonic exudation. The relative proportion 
of the elements of the blood in the exudate varies in different cases. 
Fibrin is always present, immediately coagulating in delicate filaments 
within the interstices of which the corpuscles are lodged. The white cor- 
puscles in some cases are much in excess of the red, while in others the 
red predominate. The lung in the second stage contains no air, has a 
greater specific gravity than water, is friable so as to be readily torn and 



ANATOMICAL CHAEACTEES. 517 

penetrated by the finger. The torn surface in the adult presents a gran- 
ular appearance, each granule being the contents of an air-cell. In the 
child the granules are not distinct on account of the small size of the air- 
cells, but the volume of the inflamed lobe is somewhat increased as in the 
adult. 

The stage of gray hepatization succeeds, in which the volume of the 
lung is still greater. The change of color is due partly to the compression 
of the capillaries by the inflammatory material, partly to the destruction 
of the red corpuscles, and disappearance to a greater or less extent of 
their coloring matter, while the white corpuscles (pus-cells) remain, but 
more to commencing fatty degeneration in the exudate prior to its lique- 
faction. In favorable cases the lung soon returns to its normal state, the 
liquefied substance which filled the alveoli being in part absorbed, in part 
expectorated. 

Croupous pneumonitis often causes inflammation of the portion of the 
pleura which covers it. Pleuritis developed in this way is circumscribed, 
but it frequently' extends beyond the inflamed parenchyma to the distance 
of one or two inches. Bronchitis is also a common- accompaniment. It 
may be general, in which case it occurs independently, or be limited to the 
tubes lying within the inflamed lung, in which case it results like the 
pleuritis from the pneumonitis. It is seen from this description that the 
pus-cells which are produced so abundantly in the alveoli are believed to 
be chiefly exuded white corpuscles of the blood. Possibly some of them 
may be produced by proliferation of the epithelial cells, Avhich line the 
alveoli, in the same manner as they are believed to be produced in the 
bronchial tubes. 

Catarrhal pneumonitis, which is, as we have stated, for the most part 
the lobular pneumonitis of writers, and which, with an occasional excep- 
tion, is the form of inflammation in children under the age of five years, 
presents not only clinical but anatomical features, which distinguish it 
from the croupous form of the disease. Those who have witnessed few 
post-mortem examinations of young children, and whose views of the 
lesion are influenced by the expression lobular, are apt to suppose that 
there is an alternation of inflamed and healthy lobules, so that the surface 
of the lung presents an appearance not unlike mosaic work. This is a 
mistake. Although an entire lobe is seldom inflamed, as in croupous pneu- 
monitis, the inflammation commonly extends over moi*e or fewer contiguous 
lobules, but we find certain lobules in the midst of the inflamed area which 
are but slightly aflected or have escaped entirely. The extent of the in- 
flammation is ordinarily from one to three inches, but I have seen a nodule 
of true catarrhal pneumonia not larger than a pea, while every other por- 
tion of the lung was healthy. On the other hand, almost an entii-e lobe 
may appear hepatized to tli<' naked eye as in the croupous inflammation, 
but by a careful examination certain lobules will be found unaflected. 



518 PNEUMONITIS. 

Thus, in a case in the Nursery and Child's Hospital, in which death 
occurred at the age of one year from pneumonitis supervening upon per- 
tussis, an entire lower lobe, with the exception of a little of its anterior 
border, presented the appearance and feel of red hepatization, but a care- 
ful microscopic examination revealed not only the absence of fibrin in the 
exudate, showing the catarrhal nature of the inflammation, but also cer- 
tain lobules in the midst of the inflamed lung which w'ere not involved. 

The first change occurring in a lung invaded by catarrhal pneumonitis 
is congestion, whether active, as in the common form of the disease, in 
which the inflammation has extended into the lung from the bronchioles, 
or passive, as when the inflammation results from hypostasis or collapse. 
An exudation of serum, but not of fibrin, follows, and soon the epithelial 
layer which lines the alveoli begins to swell. The nuclei of the epithelial 
cells divide, the cells themselves forming large round cells with vesicular 
nuclei. These cells, to which the solidification of the lung is mainly due, 
are, therefore, on account of their origin and appearance, regarded as 
epithelial. The alveoli in catarrhal pneumonitis, it is seen, are filled 
with an inflammatory product quite different from that in the croupous 
inflammation. 

Inflammation of the ])leura over the inflamed lung, so common in croup- 
ous pneumonia, and which gives it the name pleuro-pneumonia, by which 
it is sometimes designated, rarely occurs in this disease. The seat of this 
inflammation is ordinarily the posterior part of the lungs, even when it re- 
sults from extension of the inflammation from the bronchial tubes. When 
resulting from collapse, it affects chiefly those lobules which are remote 
from the bronchi, and which the air enters only by a long circuit. 

Catarrhal pneumonitis, when it arises from extension of acute inflamma- 
tion of the bronchioles, is acute, but in those forms of the disease which 
supervene upon passive congestion it is subacute. The alveoli are less dis- 
tended by inflammatory products than in croupous pneumonia, not only 
from the absence of fibrin, but from a less amount of cells. Hence the 
volume of the inflamed lung is not so great as in that disease, and the torn 
surface, even in the adult, does not present a granular appearance. Hence, 
also, the stage of gray hepatization does not supervene so uniformly and 
regularly, since there is less compression of the capillaries in the alveolar 
walls, and the mutual pressure of the inflammatory products is less. In 
infants who have died with this form of pneumonitis, of six or eight weeks' 
duration, it is not unusual to find the affected lobules still in the stage of 
red hepatization. Cell proliferation occurs in the bronchioles of the in- 
flamed lung as in the alveoli, producing within them numerous plugs, 
which, though they obstruct the entrance of air, are not so firm as in 
croupous pneumonitis, as they are destitute of fibrin. 

In favorable cases the lung affected by catarrhal inflammation returns 
to its normal state, probably by the same process as in croupous pucu- 



CHEESY PNEUMONITIS. 519 

monitis. In other cases, especially in scrofulous and feeble children, the 
inflammation, instead of resolving, passes into what is now designated cheesy, 
or by certain writers scrofulous, pneumonitis. 

Cheesy Pneumonitis. — Cheesy degeneration of the inflammatory pro- 
duct occasionally occurs in the croupous form of inflammation, but it is 
more common in the catarrhal. I have most frequently observed it in 
New York during epidemics of measles, when this form of pneumonitis 
supervened upon the catarrhal bronchitis of that disease. Cheesy pneu- 
monitis is in its nature chronic, and attended with great reduction of the 
vital powers. 

Cheesy degeneration of the exudate or infiltrate consists essentially in 
the absorption of the liquid portion, and fatty degeneration of the solid. 
The obstruction of the circulation in the capillaries and the accumulation 
of cells in the alveoli and bronchioles which cannot be expectorated, are 
conditions which favor the cheesy metamorphosis. The appearance and 
consistence of the lung when it has undergone this change are well ex- 
pressed by the term which is employed to designate it. The cheesy mass 
consists of fatty, shrivelled, and fragmentary cells, and amorphous matter, 
in which can be traced the elastic fibres and larger vessels of the paren- 
chyma, the other histological elements having disappeared. 

The caseous mass after a time softens, attracting moisture from the sur- 
rounding tissues. The molecular detritus and the shrivelled cells are now 
suspended in a liquid, and, like any dead matter, they are irritants to the 
surrounding lung-substance. The bronchial tube which supplies the dis- 
eased lobule, and which in many instances was the starting-point of the 
disease, again becomes pervious, either by softening of the plug or by ulcer- 
ation at a higher point upon its walls, and air is admitted, which promotes 
the putrefactive process and chemical changes of the caseous substance. 

The lesion now described is that of pulmonary consumption, a disease 
not infrequent in children of two or three years. There are as yet no 
tubercles, but the presence of softening caseous material in the lungs very 
frequently leads to their development (see Art. Tuberculosis), and accord- 
ingly, before the case ends, clusters of tubercles may appear in the connec- 
tive tissue and walls of the vessels of the lungs and in other organs. 

In the subsequent progress of cheesy pneumonitis, if the patient live 
sufiiciently long, there occurs more or less expectoration of the oflJending 
substance, producing a cavity. Around the cavity a vascular pyogenic 
membrane forms, upon which granulations arise. These granulations, 
which produce pus abundantly, and from which small extravasations of 
blood are frequent, are gradually transformed into connective tissue. If 
the dead portion is expectorated, and there is a siugle small cavity, the 
child may recover, the empty space being fiually filled up by the exten- 
sion of the granulations, and the production of a cicatrix, which contracts, 
producing a puckered appearance. Ordinarily, however, there are several 



520 PNEUMONITIS. 

depots of cheesy matter, and several cavities resulting, whicli continue to 
enlarge by the continued softening of cheesy matter in their walls. Often, 
also, certain of the cavities intercommunicate. The bronchial glands un- 
dergo hyperplasia, and certain of them are apt, also, to become cheesy. 
As the disease advances, the suppuration and expectoration increase. The 
fatal result occurs sooner in children than in adults, and, therefore, the 
lesions, destructive and inflammatory, observed at autopsies, are ordinarily 
not so far advanced in the former as in the latter. Other unfavorable 
changes may occur in the hepatized lung, but cheesy degeneration is the 
most common and noteworthy. 

Whether it is possible to inflate a lung which presents to the naked eye 
the appearance of pneumonitis, has long been regarded as a reliable sign 
of the presence or absence of inflammatory consolidation. The facts as 
regards the possibility of insufflation are these: In croupous pneumonitis, 
when it has passed beyond the first stage, insufflation is impossible in the 
lung of the child as well as adult, with the utmost force of the breath. We 
produce emphysema in healthy portions of the lungs, while the inflamed 
area is not encroached upon. 

On the other hand, in catarrhal pneumonitis, which we have seen is the 
common form of pulmonary inflammation in children under the age of 
three years, and in which there is less distension of the air-cells by inflam- 
matory products, the lung can be inflated, except in protracted cases, but 
when fully inflated the solidified lobules can still be felt between the thumb 
and fingers. In j^rotracted catarrhal pneumonitis, as well as in protracted 
collapse, which, indeed, may and often does become a pneumonitis, full 
inflation is impossible. Central portions still remain impervious to air. 
While, therefore, the possibility or impossibility of inflating a lung re- 
moved from an adult, and which presents to the naked eye the appearance 
of pneumonic solidification, is a valuable sign as indicating whether or not 
the disease was pneumonitis, in the child little importance can be attached 
to it. 

Symptoms. — Croupous pneumonitis commonly begins abruptly, or it is 
preceded for a brief period by symptoms of a cold. In the adult, the abrupt 
commencement is ordinarily with a chill. lu the child, there is often a 
sensation of chilliness, but a distinct chill is not common. Convulsions 
sometimes occur in place of a chill. Catarrhal pneumonitis, being ordi- 
narily a secondary disease, begins in a more gradual w'ay, its symptoms be- 
ing preceded by, and associated with, those of the primary affection. 

The symptoms of acute pneumonitis, whether catarrhal or croupous, are 
the following : Anorexia, thirst, restlessness, elevation of temperature, ac- 
celeration of pulse according to the intensity of the inflammation and the 
feebleness of the patient, flushed face, a countenance indicative of suffering, 
accelerated respiration, with an expiratory moan. These symptoms ai-e 



SYMPTOMS, 521 

constant in the acute inflammation unless of the mildest form. Those which 
are important I shall describe more fully. 

The expiratory moan is described by writers as a pathognomonic symp- 
tom of this disease, or of pleurisy. It is evidently due to the pain expe- 
rienced by the friction of the inflamed pleura. As a rule, the expiratory 
moan does indicate either pneumonitis or simple pleuritis ; but there are 
exceptions. It may occur, for example, from indigestible substances in the 
stomach and intestines, giving rise to acute dyspepsia ; or from certain 
forms of abdominal inflammation, which render movements of the dia- 
phragm painful, as diaphragmatic peritonitis. 

The cough in the first days of pneumonitis is often dry or hacking and 
painful. It afterwards, if the case is favorable, becomes looser, and is painless. 
We very seldom observe in the child the bloody sputum which characterizes 
pneumonitis in the adult, since in catarrhal inflammation there is little or 
no exudation of blood-corpuscles. The sputum, which in this form of the 
disease is the product of secretion and cell proliferation, is at first thin and 
frothy, but afterwards thicker and less tenacious from the greater number 
of cells. There is often, in the first period of the inflammation, pretty 
severe and constant headache, the patient complaining of the head, if old 
enough to speak, before he does of the chest. In a severe attack the child 
at this period lies with the eyes shut, apparently in a half-conscious state, 
fretful if spoken to or aroused, so that the physician might be led to sus- 
pect the presence of cerebral disease. If there is vomiting, accompanied 
with sudden twitching of the muscles, and convulsions — symptoms which 
sometimes occur — the liability to error in diagnosis is greatly increased. 
Cerebral symptoms are more prominent in the commencement of pneu- 
monitis than subsequently. As the disease advances they subside, and 
symptoms referable to the chest become more conspicuous. 

The breathing is, as I have said, accelerated. Thirty or forty respira- 
tions per minute are common, and, in severe cases, the number reaches sixty 
or even eighty. In infants there is greater frequency of respiration than 
in children. In those at the breast, if the dyspnoea is urgent, nutrition is 
sometimes seriously interfered with, since in these severe cases respiration 
is performed more through the mouth than nostrils, so that if the infant 
seizes the nipple, it is forced to relinquish it in order to breathe. Dilatation 
of the aloe nasi, and depression of the infra-mammary region, accompany 
inspiration. The dyspnoea in catarrhal pneumonitis is often due in great 
part to accompanying bronchitis. 

The temperature in mild cases of pneumonitis is elevated to about 101° 
to 103°; in severe cases it may reach 105° or even 107°, the former being 
the highest observed by Mr. Squire. In ninety-seven observations made 
by M. Roger, the average temperature was 104° during the active period 
of the inflammation. The face is therefore flushed, and the heat of surface 



522 PNEUMONITIS. 

puugent, except iu weakly children, iu whom, even in severe and active 
inflammation, the face is sometimes pale, and the extremities of natural or 
less than natural temperature. 

The tongue is moist, and covered with a light fur ; the thirst is such that 
nutriment may be given in the form of drinks, when the loss of appetite 
prevents the use of solid food. The bowels are usually constipated. The 
secretions, in the first and second stages, are diminished. The urine is more 
deeply colored than in health, and in vigorous patients it deposits urates 
on cooling. The chlorides are also deficient, or absent from the urine, as 
long as the inflammation is extending. 

In favorable cases, in from seven to ten days the heat and thirst decline ; 
the pulse and respiration gradually become less frequent ; the cough looser ; 
the features have a more placid or contented expression ; the appetite re- 
turns, and the patient is again amused by playthings. The improvement 
is progressive, but gradual. A slight cough is occasionally observed for 
two or three weeks after convalescence is fully established. 

Death in the acute stage of the inflammation commonly occurs from 
asthenia. The pulse gradually becomes more frequent and feeble, the 
respiration more oppressed, and finally, near the close of life, the face and 
extremities become cool. Occasionally death results from apnoea, due iu 
great part to coexisting bronchitis. In exceptional instances it occurs from 
convulsions, followed by coma, especially in the first week. In those pro- 
tracted cases in which the inflammatory products have undergone cheesy 
degeneration death occurs from asthenia. 

Such are the symptoms and progress of ordinary acute pneumonitis in 
children. When the inflammation is subacute, as in those forms of the 
disease which result from collapse or hypostasis, the symptoms are less 
pronounced. The respiration in such cases is but moderately accelerated, 
is attended by little pain, and therefore the expiratory moan is often 
absent. An occasional short, dry cough occurs, with so little increase of 
temperature and quickening of the pulse that the pneumonitis is apt to 
be overlooked by the physician, the symptoms being referred to bronchitis. 
Pleuritis does not occur in connection with this form of pneumonitis, 
except when a small abscess or gangrene occurs in an afiected lobule 
directly under the pleura. A few such cases I have observed. 

Tubercular pneumonitis extends over much or little of the lung accord- 
ing to the amoiiBt of tubercles. The symptoms are like those of severe 
primary pneumonitis,, superadded to such as pertain to tuberculosis. This 
inflammation, when once established in the consumptive child, commonly 
continues till the close of life. I have sometimes had these cases under 
observation for several consecutive weeks, even mouths, and during the 
whole time there was not only acceleration of pulse and respiration, but 
the expiratory moan. As regards pneumonitis occurring iu hooping-cough, 
it is an interesting fact that its symptoms modify those of the primary dis- 



PHYSICAL SIGNS. 523 

ease, so that, during the active period of the inflammation, the paroxysmal 
cough diminishes, and a short, hacking cough and expiratory moan occur 
in place. As the inflammation abates, the spasmodic cough returns. Pneu- 
monitis, occurring in measles, is more obstinate, protracted, and dangerous 
than the primary form. It usually commences about the period of the 
decline of the eruption, and, in favorable cases, continues two or three 
weeks. It is then a sequel, rather than complication. 

Physical Signs. — The physical signs of pneumonitis in infancy and 
childhood are the same as in the adult, but in a large proportion of cases 
they are less distinct. In a majority of patients under the age of three 
years the crepitant rale is not observed. This is due to the small size of 
the alveoli at this age. I have now and then detected it in quite young 
children, in whom it is a finer rale than in the adult. If observed, it is, 
of course, positive proof of the existence of pneumonitis. The physical 
signs, therefore, in the first stage of the inflammation, are often obscure in 
consequence of the absence of the pathognomonic rale. The vesicular 
murmur is somewhat intensified through the chest, and there is in this stage 
slight dulness on percussion over the seat of the inflammation due to 
engorgement of the vessels, but it is difficult to appreciate this. 

In the second stage, which supervenes more or less rapidly, the physical 
signs are more distinct. Bronchial respiration is in most cases detected, 
higher in pitch than the vesicular murmur, with the sound of expiration 
higher than that of inspiration. The voice of the patient is transmitted 
to the ear applied over the seat of the disease, and often a peculiar vibra- 
tory sensation is communicated to the hand applied over the part, so that 
it is possible to locate the disease by palpation alone. There are frequently, 
in the second stage, and sometimes in the first, coarse mucous rales in 
various parts of the chest from coexisting bronchitis. 

Percussion, in the second stage, elicits a dull sound as compared Avith 
that produced on the opposite side of the chest. The dulness corresponds 
in extent with the solidification, and with the bronchial respiration. 

As the inflammation abates, the dulness on percussion gradually dimin- 
ishes, and the bronchial respiration is succeeded by the subcrepitant rale. 
Often, for a considerable period after convalescence is established, moist 
rales are observed in the chest, and sometimes the dulness on percussion 
does not entirely disappear till after the health is fully restored. 

In catarrhal pneumonitis the physical signs are not so distinct. This is 
due in part to the limited extent of the inflammation, in part,, in many 
cases, to its subacute character, and in part to the fact that this inflamma- 
tion is apt to be double, especially in those frequent cases in which the 
cause of the disease is hypostatic congestion. 

Diagnosis. — In the adult, pneumonitis is a disease of easy diagnosis. 
In infancy and childlnxHl, on ihc other hand, diagnosis is often difiicult. 
Acute primary pneumonitis in young children is apt to be confounded with 



524 P^'EUMOXITIS. 

meningitis, or one of the essential fevers, if the examination be made 
within the first or second day. In children over the age of three or four 
years, it is most frequently mistaken for remittent fever. The two diseases 
do, as regards symptoms, resemble each other. Both are characterized by 
great elevation of temperature, rapid pulse, languor, and drowsiness, and 
in both there is apt to be a cough even from the first day. But remittent 
fever (I include for the present under this term also typhoid fever) usually 
begins more gradually than pneumonitis. It is preceded for a few days 
by symptoms of mild indisposition, though there are exceptions, and it 
may commence quite abruptly. The expiratory moan occurring in pneu- 
monitis in most cases by the second or third day is a symptom of great 
diagnostic value. But positive proof of the nature of the disease is afforded 
only by auscultation and percussion. Scarlet fever, in its commencement, 
bears some resemblance to acute primary pneumonitis. The points of dif- 
ferential diagnosis ai'e the redness of the buccal membi'ane and the fauces, 
and the efflorescence upon the skin in scarlet fever on the one hand, and 
on the other the rational and physical signs of pneumonitis, which have 
been described. 

Greater difficulty attends the diagnosis of acute pneumonitis from bron- 
chitis and pleuritis. The presence of the expiratory moan, if it is pretty 
constant and marked, is sufficient to exclude bronchitis, unless as a com- 
plication, but the physical signs constitute the only reliable means of exact 
diagnosis. The presence or absence of bronchitis is readily determined 
by auscultation. The physical signs should be carefully noted, in order 
to determine if there is some point of solidification. 

Solidification gives rise to duluess on percussion, bronchial respiration, 
and bronchophony. These three signs coexisting afford sufficient proof of 
pneumonitis, unless there is tubercular consolidation or possibly collapse 
supervening on suffocative bronchitis. The history of the case aids in 
determining whether there is either of these diseases. Moreover, collapse 
occurs later after the attack commences than hepatization, and does not 
produce so distinct bronchophony or bronchial respiration as are observed 
in the common form of pneumonitis. 

Pleuritis with effusion may present physical signs which bear consider- 
able resemblance to those in pneumonia; but in pneumonia, except when 
associated with tubercular deposit, the dulness on percussion is not so 
great as that from pleuritic effusion, nor does the line of dulness vary 
according to the position of the child. In pleuritic effusion in a young 
child the respiratory murmur can often be heard with the ear applied 
over the liquid, but it is indistinct and transmitted through the liquid 
from a distance. The practiced ear is able to discover the difference be- 
tween it and the bronchial respiration of pneumonitis. Vocal fremitus, 
which is absent in pleuritic effusions, is another reliable sign of pneumonia. 



PROGNOSIS TREATMENT. 525 

Occasionally the physical signs indicate the coexistence of pneumonitis 
and pleuritis. 

In catarrhal pneumonitis it is often difficult to determine certainly the 
nature of the disease, since the physical signs, if there is but little extent 
of inflammation, are absent or indistinct. I have often, in post-mortem 
examinations, found so small a part of the lung hepatized that it could 
not possibly have produced any appreciable dulness on percussion, bron- 
chial respiration, or bronchophony. Such cases are apt to pass for bron- 
chitis, and, practically, this matters little, since the treatment required by 
the two is not dissimilar. 

Prognosis. — Primary pneumonitis, affecting only one lung, if properly 
treated, in most instances terminates favorably in children, and even in 
infants. If double, it is, as in the adult, much more serious, and in a large 
proportion of cases, fatal. Secondary pneumonitis, pneumonitis occurring 
in measles, hooping-cough, tuberculosis, or resulting from hypostatic con- 
gestion in the course of some exhausting disease, is, on the other hand, 
more frequently fatal. As death usually occurs from asthenia, the younger 
the child and more feeble the constitution, the greater the danger. 

Unfavorable symptoms are a pulse becoming more and more frequent 
and feeble, pallor of countenance, inability of the patient to support the 
head, total loss of appetite, refusal to notice or be amused by playthings, 
absence of tears when crying — a symptom which the Fi-ench writers have 
pointed out — and the appearance of pemphigus on the face or elsewhere. 

Indications on which a favorable prognosis may be based are moderate 
acceleration of pulse, pneumonitis primary and limited to one side, ability 
to support the head or sit erect, being amused by playthings, etc. 

Treatment. — The treatment of the two forms of pneumonitis, namely, 
catarrhal and croupous, the former occurring chiefly under the age of 
three year's, and being secondary, the latter occurring in most patients 
over that age, require to be considered separately as much as do their 
symptoms and anatomical characters. 

Catarrhal joneumonitis when developed from and upon a bronchitis,^ as 
it so often is, requires for the most part the continuance of the remedies 
which are appropriate for the primary disease. (See Art. Bronchitis.) 
But from the fact that it is secondary, and in children of a tender age, 
and since the danger as regards the pneumonitis is due to asthenia, more 
actively sustaining measures are demanded than might be required for 
the uncomplicated bronchitis. When the pneumonitis has continued a 
few days, and often in its commencement, carbonate of ammonia and 
alcoholic stimulants are needed, and the diet from the first should be 
nutritious. An opiate, as the compound tincture of ipecacuanha, should 
be added to the cough-mixture, if there is restlessness or insufficient sleep, 
and the external treatment recommended for bronchitis should be con- 
tinued. In that form of catarrhal pneumouiti& which Is due to passive 



526 PXEUMOXITIS. 

congestion or hypostasis, in the causation of which debility is an important 
factor, tonic and stimulating measures are still more imperatively required. 
Frequent change of position is useful in such cases. 

In Croupous pneumonitis, if seen at the commencement or within a few 
hours of the commencement, an emetic of ipecacuanha may be given, as 
recommended by Trousseau. This acts promptly as a cardiac sedative, 
diminishing somewhat the afflux of blood to the lungs, and moderating 
the inflammation. It should not be employed except at the period men- 
tioned. 

The abstraction of blood by leeches or otherwise has justly fallen into 
disrepute in the treatment of the inflammations of children, as it is too 
depressing. But while the application of leeches in catarrhal pneumonitis 
is very rarely admissible, on account of the tender age of the patient and 
the secondary character of the inflammation, they may be useful in robust 
children with croupous pneumonitis, if applied sufficiently early, namely, 
within the first twelve hours. Two leeches are sufficient for a child of five 
years. When solidification of the lung has occurred, the time for the ab- 
straction of blood is past. But Ave have in aconite and veratrum viride 
efficient substitutes for bloodletting, which, by their sedative effect on the 
heart, diminish the exaggerated afflux of blood to the inflamed lung, and 
thus enable us to meet the indication of treatment in the first stage of the 
inflammation. It is important in all severe cases to preserve the blood 
and the strength, for the danger in the end is chiefly from asthenia. 
Aconite as a cardiac sedative in the treatment of children is safer than 
veratrum viride; it is not necessary to watch its effects so carefully. 

The following will be found a useful formula for a child of five years : 

R. Tinct. ipecac, comp. (Squibb's), gtt. xvi-xxiv. 
Tinct. rad. aconite, gtt. xvj. 
Syr. bal. tolut., 
Aquae, aa ^j. 
Dose, one teaspoonful every three hours ; or the aconite may be given alone, 
dropped in sweetened water or syrup of tolu. 

If bronchial respiration, bronchophony, and dulness on percussion are 
present, indicating the second stage ; in other words, if it appear from the ' 
signs that the inflamed lobe or lobes are hepatized, little benefit accrues 
from the farther use of aconite or veratrum viride, and harm may result. 
In this stage the above prescription, with the aconite omitted, may be con- 
tinued, or the following may be employed : 

B- Morph. sulphat., gr. j. 
Syr. ipecacuanha, ^j. 
Syr. bal. tolut., ,f iij. Misce. 
Dose, one teaspoonful every three hours to a child of five years. 

The remarks made in reference to the use of quinia in the treatment of 



TREATMENT. 527 

bronchitis apply with still more force to its use in both the catarrhal and 
croupous forms of pneumonia. In secondary pneumonitus and primary 
occurring in feeble children this agent is in many instances preferable to 
any other medicine for the purpose of reducing the temperature and pulse, 
since it produces this result without depi'ession. It may be administered 
in these cases from the iirst day, and its use may be continued longer than 
would be safe for aconite or veratrum viride. 

When the inflammation begins to abate there is usually progressive 
improvement. Many now recover with simple mucilaginous drinks or 
mild expectorants for the accompanying bronchitis, as syrup of ipecacu- 
anha or squills in small doses. Others require more sustaining measures, 
and for such carbonate of ammonia is preferable with, perhaps, quiuia. 
In all severe pneumonias it is of the utmost importance to sustain the 
vital powers, even from the commencement of the inflammation. There 
can be no doubt that the great error in the therapeutic management of 
children with this malady has been the employment of medicines which 
reduced the strength when gentler measures or those of a sustaining nature 
were required. Alcoholic stimulants are required sooner or later in most 
cases ; at an early period in feeble children and in secondary forms of the 
inflammation. Infants may take two or three drops of Bourbon whisky 
or brandy for each month of their age eveiy two or three hours. The 
diet should be nutritious, consisting of milk, animal broths, and the like, 
unless during the first three or four days in robust children. 

The bowels should be kept open, as an important part of the treatment 
of croupous pneumonitis in its first stages. A small dose of castor oil, 
Rochelle salts, or citrate of magnesia should be given if there is any ten- 
dency to constipation, and repeated from time to time if required. A 
saline aperient by its derivative and refrigerant effect in some cases obvi- 
ates the necessity of employing cardiac sedatives. 

Local treatment is required in all cases ; counter-irritation should be 
produced as soon as possible over the inflamed lobe, by mustard, iodine, 
or some stimulating liniment, and, except at the time of this application, 
the chest should be constantly covered with an emollient poultice, or with 
a cloth wrung out of wai'm water and covered with oil-silk. I prefer, 
iiowever, the constant application, under the oil-silk, of the following 
poultice, made large but thin as the cover of a book, and therefore light : 

R. Pulv. siiiapis., Jss. 

Pulv. seniin. lini, 5viij. Misce. 

In a large proportion of cases vesication is not required. If the inflam- 
mation is extensive, and the symptoms urgent, it is occasionally advisable 
to blister, and the cantharidal collodion should be used for this purpose. 
A safe, almost painless, and at the same time efiicient, mode of applying 
this is in spots as large as a ten-cent piece, half a dozen, more or fewer 



528 P L E U E 1 T I S. 

according to the extent of the inflammation, the skin of course remaining 
sound between them. This mode of application obviates the danger of 
producing a troublesome sore, which sometimes occurs in children from 
the ordinary mode of vesication. 

In cheesy pneumonitis, which is always accompanied by au?emia, and 
great reduction of the vital powers, carbonate of ammonia with citrate of 
iron and ammonia equal parts, or cod-liver oil administered three times 
daily with two drops or more of syrup of iodide of iron, will be found use- 
ful, as is also quinine with iron. The patients require the most nutritious 
diet and alcoholic stimulants. In the local treatment of this form of in- 
flammation vesication, even so mild as that by cantharidal collodion, should 
be avoided. 



CHAPTER yil. 

PLEURITIS. 

Pleueitis occurs in children, as in adults, both as a primary and 
secondary disease. Secondary pleuritis, or pleuritis occurring during the 
course of other diseases, and due to those diseases, is common in infancy 
and childhood, as it is at other ages. Idiopathic pleuritis was formerly 
believed to be very rai-e in children under the age of five years, though 
not infrequent in those above that age. But greater precision in the ex- 
amination of cases, more accurate means of diagnosis, more knowledge of 
the nature of diseases, and more frequent autopsies have enabled the pi'o- 
fession of the present time to correct this as well as many other errors, 
and we now know that primary pleuritis is not very infrequent in young 
children, even in infants. There can be no doubt that many cases of this 
malady in young children have been, and even now are mistaken by good 
practitioners for other diseases, especially for pneumonitis, or if the disease 
is to a certain extent latent, have been mistaken for remittent or malarious 
fever, or the fever due to dentition or intestinal irritation. I have records 
of several cases occurring both in family and hospital practice, in which 
young children perished with a wrong diagnosis or without a diagnosis, 
when the post-mortem examination revealed a pleuritis often of long stand- 
ing. Thus, in one case of fatal empyema commencing at the age of six 
months and continuing several mouths, chronic pneumonitis had been 
diagnosticated by a physician well known to be thorough in his examina' 
tions and usually accurate. In another case, which proved fatal at about 
the age of one year, the child, who lived in a malarious locality, had been 
for weeks under treatment for supposed malarious disease, but in this case 
diagnosis was easy with a proper examination, for at my first visit, which 



PLEURITIS. 529 

was when the child Avas dying there was decided daln-ess on percussion 
over the posterior portion of the right side of the chest. In this case the 
right lung was adherent to the ribs anteriorly and laterally, while pos- 
teriorly it was separated by pus which crowded forward this orgB,n so 
that its posterior surface was concave. 

The following statistics probably show about the average frequency of 
primary pleuritis in young children. Of 404 children under the age of 
twelve years, whom I treated in private practice during the months im- 
mediately preceding May, 1874, two under the age of three years had 
primary pleuritis, and three others under the same age had pleuritis as 
the main disease apparently, but from the physical signs it was believed 
that there was also inflammation of a small portion of the lung in each 
case. One of the children having uncomplicated primary pleuritis was a 
girl aged two and a half years, whose previous health had been good. On 
April 2d, she was suddenly taken sick with active febrile movement. Her 
pulse was about 180 per minute, counted with difficulty on account of the 
fretfulness, and the respiration was 88, and accompanied by an expiratory 
moan. At first no marked physical signs were observed in .the chest, but 
within a few days a distinct clicking pleuritic sound was observed in the 
left infra-scapular region, and later still a creaking sound in the same 
place, during respiration. No perceptible difference was observed in the 
percussion-sound upon the two sides of the chest. The febrile movement 
continued nearly a month when it gradually abated, and the health of the 
patient was fully restored. The temperature on five of the six days, from 
April 18th to 24th, was 102°, 103°, 100^°, 99|°, and 102°, and the pulse 
on two of these days was recorded at 136 and 140. This child was ex- 
amined by one of the most accurate auscultators in ISTew York, who believed 
that there was almost no exudation of serum in the chest but an exudation 
of fibrin of little thickness. The second case was an infant aged eighteen 
months, who for six weeks had had an expiratory moan with febrile move- 
ment. The parents stated that his general health previously to his present 
sickness had been good, but the family were destitute, and his system had 
probably been in a more or less cachectic state from bad regimen. This 
child when first visited was feeble and wasted, as if from tubercular dis- 
ease. The percussion-sound was flat over the lower half of the right side 
of the chest. A few drops of pus were withdrawn from the pleural cavity 
by the hypodermic syringe introduced a little below the angle of the 
scapula, and then the diagnosis being established, §iij to giv of very thick 
pus were removed by the aspirator when it ceased to flow. The respira- 
tion afterwards was less painful and the child slowly but progressively 
convalesced. There was in this as in the preceding case no appreciable 
bulging of the intercostal spaces, and no difference in the dimensions of 
the two sides. 

In hospital and dispensary practice the proportion of cases of primary 

34 



530 PLEUEITIS. 

pleurisies is iu my opiniou somewhat larger than in private practice, since 
the cachexia so common iu children in these institutions is, as we will see, 
one of the predisposing causes of this form of inflammation. The frequency 
of secondary pleurisy varies in difierent years or seasons, according to the 
prevalence of the maladies on which it depends. Thus during extensive 
epidemics of scai'let fever, pleuritis is more frequent than at other times. 

Cause. — The ordinary cause of primary pleuritis is the same as that of 
most other primary inflammations, to wit, the impression of cold. This 
malady is, therefore, most common in the cool months, and in times of 
changeable temperature. Feebleness of constitution is an acknowledged 
predisposing cause iu children. Therefore, children whose blood is im- 
poverished by anti-hygienic influences to wdiich they are exposed, or by 
previous disease, are more liable to jDleuritis than those who possess a sound 
constitution. Hence the fact that a larger proportion of cases occur among 
foundlings and the children of the city poor, than among those who are 
well nourished, and live iu comfortable cii-cumstances. 

It is probably due to both the causes now mentioned, namely, cai-eless 
exposure by nurses to cold or to currents of air on the one hand, and 
cachexia ou the other, that pleuritis is common in newborn infants iu 
foundling asylums. Cases like the following are not infrequent. In 1867 
I made the post-mortem examination of a foundling who died in the New 
York Infant Asylum. Its age was about one month. A small amount 
of pus, not more than one drachm, was found in one pleural cavity, and 
less than this quantity iu the other. Ou both sides there was nearly gen- 
eral injection of costal and pulmonary pleura, but with little or no sero- 
fibrinous exudation. There was also pus at the root of each lung, extending 
somewhat over the lung, but under the pleura. The fact of a double pleu- 
ritis without pulmonary disease indicated a constitutional cause, but there 
was no apparent cause of this nature, apart from the impoverishment of 
the blood. 

Billard, whose observations were made among foundlings in the Hospice 
des Eufants Trouves, says : " Pleurisy is more common among youug in- 
fants than is generally supposed ; it often appears without the lungs par- 
ticipating in the inflammation. I have seen several infants die immediately 
after birth from this affection." He relates two cases of double idiopathic 
pleuritis ending fatally at the ages of two and ten days. {Diseases of In- 
fants, page 419.) Mignot, whose observations were made in the same in- 
stitution, also records ten pleurisies, five of which were idiopathic, in one 
hundred and nineteen necropsies of uewborn infants. (Maladies j^endant 
la Premier Age.) 

The chief causes of secondary pleuritis are tubercles, pneumonitis, scarlet 
fever, and the entrance of some morbid product as pus into the pleural 
cavity. Tubercles situated under the pleura are, as is well known, a com- 
mon cause of this inflammation at any age, but pleuritis is less frequent in 



CAUSES. 531 

the tuberculosis of children than of adults. This difference is due to the 
fact that tubercles in children, especially in young children, are ordinarily 
small, and disseminated in various organs through the system, so as to pro- 
duce comparatively little inflammation and destruction of the contiguous 
tissues before the fatal ending. 

A similar difference exists in regard to the frequency of pleuritis as a re- 
sult of pneumonitis in the two periods. Croupous j)neumonia, which is the 
common form of pulmonary inflammation in adults, ordinarily involves 
the j)leura, as is well known. On the other hand, catarrhal pneumonia, 
which is the form of inflammation common iu childhood, commonly occurs 
without exciting a pleuritis. 

One of the exanthematic fevers, namely, scarlatina, not infrequently also 
produces pleuritis, occurring either as a complication or sequel. This re- 
sult appears to be sometimes due to the altered state of the blood resulting 
from the presence of the scarlatinous virus. In other instances it is prob- 
ably the result of the retained urea consequent on scarlatinous nejohritis, 
for pleuritis is a common complication of Bright's disease. 

In young children pleuritis is sometimes due to the discharge into the 
pleural cavity of some morbid product, as pus, softened tubercle, or decom- 
posed lung-tissue, which from its very irritating effect produces a fatal in- 
flammation. I have preserved the records of several such cases, which I 
have observed. 

A retropharyngeal abscess, descending behind the oesophagus, has been 
known to cause fatal pleuritis by bursting into the pleural cavity. A sup- 
purated bronchial gland or abscess in the walls of the chest occasionally 
produces the same result. In January, 186 i, I presented to the New York 
Pathological Society the lungs of an infant, with the following history : 
R., aged 9 months, of strumous parentage, and whose only sister had suf- 
fered severely from strumous ophthalmia and periostitis, was taken sick 
about December 19th, 1863, with febrile movement, attended by restless- 
ness, but apparently without any serious indisposition. On the 22d, the 
mother called my attention to a prominence just below the right clavicle. 
This proved to be an abscess. A poultice was applied, in the expectation 
that it would discharge externally. On the 24th of December, however, 
the prominence subsided, and immediately the symptoms were greatly ag- 
gravated. The pulse rose to 160 per minute, the resi^iration to 60 or 80, 
and expiration was accompanied by a moan, so common iu acute inflam- 
mation of the pleura or lung. Within a day or two after the disappear- 
ance of the tumor, and the exacerbation of the symptoms, dulness on per- 
cussion was observed on this side, and this increased till there was perfect 
flatness. The right pleural cavity had evidently filled with liquid, the 
acceleration of pulse and respiration continued, the patient grew more and 
more feeble, and death occurred December 31st. 

At the autopsy, on dissecting away the integument from the right side 



532 PLEUETTIS. 

of the chest, an abscess was opened, containing nearly an ounce of pus, 
located at the point where the tumor had been observed. There was a 
small round opening from this abscess directly into the cavity of the chest, 
so that, on depressing the ribs, liquid escaped from the cavity. On re- 
moving the sternum, the liquid was found to consist mainly of serum with 
lymph, and at the bottom of the liquid was considerable pus. I have met 
one other case, apparently almost identical with this, the infant being seven 
months old, but I did not attend it in the latter part of its sickness. The 
abscess in the case which I have detailed was obviously strumous, prob- 
ably occurring from glandular inflammation. This mode of production 
of pleuritis, namely, by the discharge of an abscess located in the thoracic 
walls, is no doubt rare. It was so considered by the members of the Path- 
ological Society. 

We occasionally meet cases, especially in foundling asylums, which have 
a different origin. An indolent pneumonitis occurs over a circumscribed 
area in the posterior part of the lung, whether it results from hypostasis, 
or from exposure to cold. A minute abscess, often not larger than a pin's 
head, or a small shot, occurs in the inflamed part. Perhaps this abscess 
is located in a bronchiole, and it may results from the muco-pus, which 
has collected in this tube, and was not expectoratecl on account of the low 
vitality and feeble functional activity of the tissues. The pus approaching 
the pleural surface, produces circumscribed pleuritis at that point, or open- 
ing into the pleural cavity, gives rise to general pleuritis. Often several 
of these abscesses are observed in the inflamed parenchyma. The follow- 
ing are cases in point : 

Case 1 — I. M , male infant, was admitted into the Nursery and 

Child's Hospital, May 19th, 1859, at the age of two months. He was very 
delicate at the time of admission, and had slight bronchitis, but, being 
placed with a wet-nurse, he gradually improved. About the middle of 
July, attacks of diarrhoea occurred, each lasting from one to two days, and 
from this time his health declined. Furuncular eruptions appeared on the 
head and neck, and, though sustaining measux^es were employed with medi- 
cines to control the diarrhoea, there was progressively more emaciation 
and feebleness. 

The records on August 1st state, "Continues to fail, apparently from the 
attacks of diarrhoea ; the furuncular eruption continues." On 3d of Au- 
gust, he died suddenly of apnoea, though there has been no symptoms to 
direct attention to the chest. Possibly he had a slight cough, which had 
escaped detection. 

Autopsy eight hours after death. — Stomach and jejunum healthy ; mucous 
membrane lining the lower part of the ileum and the entire colon vascu- 
lar, and that of the colon considerably thickened ; mesenteric glands en- 
larged, and of a lighter color than in health ; right lung compressed by a 
sero-flbrinous exudation, so as to occupy a small space, though the amount 
of liquid was not more than two ounces; nearly the entire pleura, visceral 
and parietal, on this side, was covered with a fibrinous deposit of a creamy 
appearance. Some of this had settled in the depending portion of the 



ANATOMIC A.L CHARACTERS. 533 

cavity. This lung could be inflated, excej)t a little of the lower lobe, 
which was hepatized. 

On the left side, the lung also occupied a very snaall space, being col- 
lapsed ; the upper lobe could be readily inflated, when it had the elasticity 
of healthy lung ; the lower lobe had a healthy appearance, and could be 
inflated, except a portion in the posterior aspect, measuring, perhaps, an 
inch in diameter; this was partially coated with lymph, and was found to 
contain two small abscesses, one closed, the other opening externally on 
the surface of the lung and internally into a bronchial tube. On attempt- 
ing inflation, the air passed directly through this opening. The closed 
abscess contained from one-third to half a drachm of pus-corpuscles, and 
disintegrated lung-tissue, as shown by the microscope. The child was 
much emaciated. 

Case 2. — M. I , female, was admitted into the Child's Hospital, 

October 7th, 1859, at the age of about four months ; at the time of admis- 
sion was somewhat wasted with diarrhoea ; her health improved partially, 
but she remained feeble, and was at times much troubled with meteorism, 
which occasioned pain. 

On the 2d of November, she was suddenly seized with great dyspnoea, 
which terminated fatally in about a quarter of an hour. Previously to 
the dyspnoea, no cough had been noticed, or other symptoms referable to 
the chest. 

Autopsy. — Body considerably emaciated ; left lung healthy, with the 
exception of slight hypostatic congestion ; right lung adherent to the dia- 
phragm, and to a considerable part of the costal pleura, by fibrinous exu- 
dation ; this lung was somewhat compressed and noncrepitant ; the upper 
lobe floated in water ; the middle and lower sank and could not be inflated, 
or but slightly ; this portion of the lung contained a few small abscesses, 
filled with purulent matter, each holding scarcely more than one drop ; 
two of these seemed to have discharged into the pleural cavity, as the air 
passed through them in attempting to inflate, but possibly they may have 
been opened in separating the adhesions which united the two pleural sur- 
faces at this point ; two or three ounces of fluid were contained in the 
pleural cavity, consisting, in addition to serum, of fibrinous flocculi, epi- 
thelial cells from the pleura, pus-cells, and compound granular cells ; the 
lower portion of this fluid, on standing, contained so much pus that it pre- 
sented the characteristic gelatinous appearance on the addition of liquor 
potassse ; the other organs generally were normal in appearance, but the 
liver was somewhat congested, and there was also decided hypersemia of 
the mucous membrane of the colon near the ileo-coecal valve, and in the 
descending portion. 

Anatomical Characters. — The first appreciable structural change 
which occurs in pleuritis is engorgement of the vessels lying underneath 
the pleura. There can be seen, if an opportunity is presented, as in the 
case detailed above, a network of engorged capillaries. Immediately ex- 
udation commences into the connective tissue surrounding the capillaries, 
the pleura becomes dry and lustreless, and loses its epitlielial covering, and 
soon the liquor sanguinis begins to exude through it. The amount of 
serum and fibrin which escapes into the pleural cavity varies greatly in 
different cases, as does their relative proportion. 



534 PLEURITIS. 

In pleuritis due to the irritation of tubercles, or to extension of inflam- 
mation from an inflamed lung to the pleura which covers it, the amount 
of liquid exudation is ordinarily small, and occasionally almost entirely 
absent, so that the visceral and costal surfaces remain in contact. In other 
cases, namely, when the pleuritis is idiopathic, or due to uraemia, or to a 
foreign substance in the pleural cavity, the liquid effiision is considerable, 
producing more or less compression of the lung. There are, however, ex- 
ceptions to this general statement. In idiopathic pleuritis the exudation 
may consist almost entirely of fibrin, and be scanty, as in the case related 
above. On the other hand, I have seen a considerable exudation of serum 
with fibrin and pus in tubercular pleuritis, so as to compress considerably 
the lung. 

If the lung is not too firmly attached by the fibrin to the walls of the 
chest, the liquid which is exuded presses it inward towards its root or its 
point of attachment to the mediastinum. If the quantity of liquid is large 
the compression may totally exclude air from the lung, and it becomes 
like a fleshy mass, or is carmfied. 

Ordinarily the fibrin forms a layer over the inflamed pleura, at first soft 
and readily detached, but gradually becoming firmer, and shreds or floc- 
culi of fibrin, becoming separated, float in the exuded serum. When the 
inflammation has continued a short time, granulations appear on the in- 
flamed surface, receiving their supply of blood from the subpleural capil- 
laries, which have been prolonged. These granulations, wdien the serum 
is absorbed, uniting with those on the opposite side, form permanent ad- 
hesions. 

Pleuritis, except when due to a local cause seated beneath the pleura, as 
tubercle or pneumonitis, extends rapidly, soon becoming general. 

In a certain proportion of cases empyema occurs. The proportion of 
pleurisies in feeble and ill-conditioned infants which are or which become 
suppurative is very large. Hence empyema, as I have often noticed, is 
not infrequent in the institutions of this city where such infants are treated. 
Secondary pleuritis is more apt to be suppurative than is the primary in- 
flammation. The pleuritis complicating or following scarlatina is usually 
so, being therefore often more dangerous than the primary disease. 

Pleuritis has, for convenience of description, been divided into three 
stages : the first, extending from the commencement of the inflammation 
to the time when there is an appreciable amount of exudation; the second, 
from the time that the exudation is appreciable to the commencement of 
absorption ; the third stage is that of absorption or convalescence. Absorp- 
tion commences when the inflammation abates, and the rapidity with which 
the fluid disappears varies greatly in diflferent cases. As absorption occurs, 
the compressed lung gradually expands to occupy the place of the fluid. 
Sometimes absorption occurs more rapidly than the expansion, so that there 
is depression for a time of the thorax on the affected side, which gradually 



SYMPTOMS. 535 

disappears. The serum is first absorbed, and then the fibrin, undergoing 
fatty degeneration and liquefaction, is also absorbed. Occasionally por- 
tions of the fibrin instead of being absox'bed undergo calcification, after 
which there is no farther change. Commonly, as the serum is removed 
the two pleural surfaces become iDerraanently adherent, as has been already 
stated, and the lobes are likewise united to each other. 

In rare instances, in which there is a large amount of serous exudation, 
producing complete carnification of the lung, and absorption is slow, infla- 
tion never occurs, and the ribs of the affected side are permanently de- 
pressed. Respiration henceforth is performed entirely by the other lung, 
which increases somewhat in volume by hypertrophy of the air-cells. The 
compressed lung remains noncrepitant and firm, and its color somewhat 
lighter than the natural hue, from defective supply of blood and granular 
change in its anatomical elements. 

In empyema, the patient cannot recover by absorption of the pus unless 
its quantity is small. If the quantity is small or moderate the liquor 
puris is first absorbed, and the pus-cells, becoming fatty and then liquefy- 
ing, may also be absorbed and the patient recover. Indeed, in all cases of 
pleuritis, pus-cells may be detected in the exudation by the microscope. 
But if the pus predominates, or is in such quantity as to be apparent to 
the naked eye, recovery is slow and uncertain, and usually impossible by 
absorption. Empyema is, therefore, except when relieved by paracentesis, 
commonly a lingering disease, attended by many of the symptoms of tuber- 
culosis. Spontaneous cure occasionally occurs by discharge of pus into a 
bronchial tube, or externally through the walls of the chest. I have wit- 
nessed both these modes of termination. In certain instances, pleuritis on 
the left side becomes complicated with pericarditis, and, more rarely, pleu- 
ritis in the lower part of the right pleural cavity with perihepatitis, the 
inflammation extending in the one case through the pericardium, in the 
other through the diaphragm. I have met four cases of the former com- 
plication, and one of the latter in infants. 

Symptoms. — The commencement of pleuritis is, in most instances, ab- 
rupt. Sometimes we observe a rigor or chilliness as the initial symptom, 
but this is in many cases not observed. An active febrile movement is 
suddenly developed, attended by headache, and perhaps vomiting. Some- 
times the child screams violently at short intervals, as if from enteralgia 
or other severe pain. There is, usually, at this early stage, little or no 
cough, or other symptom characteristic of disease located in the chest. 
The symptoms of pleuritis obviously vary considerably in different cases, 
according to the presence or absence of other diseases, the age and robust- 
ness of the patient, and the extent of the inflammation. 

In acute primary pleuritis the pulse rises to 130 or 140 beats per minute, 
and in young children it is often more frequent, numbering 160 or 180. 
The frequency of the respiration is increased in a corresponding degree, 



536 FLEUBITIS. 

and is accompanied by the expiratory moan. The temperature is probably 
at 102° or 103°. The face is more or less flushed and indicative of suffer- 
ing. The child, if old enough to speak, complains of a stitchlike pain in 
the chest, which is most intense on inspiration and in coughing. Occa- 
sionally we can detect tenderness ou pi^essing or percussing over the affected 
side. Sometimes the patient refers the pain to the epigastric region, on 
account of the distribution of some of the fibres erf the intercostal nerves 
in this region. He assumes a certain }X)sition, as the erect, semi-recum- 
bent, or the recumbent on one side, in which there is comparative ease of 
respiration, and his suffering is less. If disturbed or removed from this 
position he is fretful, his cough is more frequent, and the respiration is 
more painful. The cough is short, dry, or hacking, unless bronchitis 
coexist, in which case there is more or less expectoration. At the same 
time those symptoms are present which are common in all inflammatory 
affections, such as anorexia and thirst. 

After some days the symptoms partially abate. The pulse and respira- 
tion are less frequent, though still accelerated, and the latter is less painful. 
Convalescence is more protracted in pleuritis than in ordinary pneumonitis. 
Several weeks frequently elapse before the liquid is fully absorbed, during 
which time there is apt to be more or less acceleration of pulse and eleva- 
tion of temperature. Certain writers state a much shorter duration of the 
febrile movement, but in the cases which I have observed, which seemed 
to be most nearly typical, I think that the temperature did not fall to the 
normal standard before the close of the third week, or even later.' The 
apjietite and strength return gradually. 

The symptoms of pleuritis, though commonly so pronounced as to direct 
attention at once to the chest as the seat of the disease, have in other 
instances such mildness that the location of the inflammation in the thorax 
can only be ascertained by a careful examination of symptoms and physical 
signs. There is, indeed, every gradation between severe and conspicuous 
symptoms, such as I have described, and latency. 

Both primary and secondary pleurisies may be latent, latency being 
more frequent in infancy than childhood. The following is a not unusual 
example : A feeble infant, aged five months and twenty-eight days, died 
suddenly at the Nursery and Child's Hospital in December, 1870. The 
attention of the resident physician had not been called to it, as it was not 
supposed to be sick, although its general condition was bad, and the nurse 
who had charge of the ward stated that it had presented no symptom of 
disease, unless possibly a slight cough during the last three or four days. 
Percussion over the right side of the chest of the corpse gave a flat reso- 
nance, and the right lung was found at the autopsy carnified, and covered 
with a loose, fibrinous layer, three-fourths of an inch thick in places, with 
but a scanty exudation of serum. 

In empyema the symptoms may not differ materially at first from those 



PHYSICAL SIGNS — AUSCULTATION. 537 

in the ordinary form of pleuritis, but absorption occurs of only a portion 
of the liquor puris. The pus produces the ordinary effects of purulent 
collections in the system, namely, loss of appetite, hectic fever, emaciation, 
loss of strength. No improvement occurs except by discharge of pus, 
either by thoracentesis or through an ulcerative opening, after which the 
child usually slowly, but progressively, recovers. In fatal cases of em- 
pyema the vital powers gradually yield, the pulse becomes more frequent 
and feeble, the face and limbs pallid and cool, and death occurs from 
asthenia. 

Physical Signs. — Skilful auscultators disagree, or are in doubt, in 
regard to the nature of certain of the abnormal sounds heard in the chest 
in cases of pleurisy. And this disagreement or uncertainty is greater in 
the examination of children than of adults; for in children, especially 
infants, many of the physical signs present peculiarities, so that they are 
less readily recognized or identified than in those who are older. Still, it 
is seldom difficult to make an accurate diagnosis by means of the physical 
signs even in the youngest child. 

Auscultation. — In the very commencement of the inflammation aus- 
cultation affords but little information. Probably we only notice that 
change in the vesicular respiration which necessarily results from the hur- 
ried breathing, A little later we observe (but this is only noticed in cer- 
tain cases, or when the visit is made at the proper moment), a dry rubbing 
sound at the seat of inflammation, which may be imitated by pushing the 
finger firmly across the dry palm of the hand. As the surface of the pleura 
becomes moistened by exudation this sound disappears. Next we observe, 
and this, too, only in certain eases, a moist friction-sound, heard near the 
surface of the chest. It may resemble closely the crepitant rale, for which 
it is sometimes mistaken, being a succession of fine friction-sounds. In 
other cases only one or two of these sounds are observed in each respira- 
tion, and they are well described by the term clicking. This crepitant, or 
clicking sound, may be heard through a considerable portion of the time 
during which the pleuritis continues, provided that there is but little liquid 
exudation, and the surfaces roughened by moist fibrin remain in contact. 
In other cases it is only heard for a brief period, disappearing when the 
contact of the surfaces is prevented by the liquid. After absorption of the 
liquid this sound may reappear, and in some cases it is heard only in the 
third stage. 

It will be recollected that the explanation which Trousseau gives of the 
occurrence of this sound differs from that which is commonly accepted. 
" This sound," says he, " which is met with in the great majority of cases of 
pleurisy is, in fact, a crepitant rale, and I have called it the crepitant rule 
of pleurisy. My interpretation of it is very simple. Just as we never 
have erysipelas without engorgement of the cellular tissue, there cannot be 
erysipelas of the pleura or j^leurisy, without an irritative engorgement of 



538 PLEURITIS. 

the subpleural cellular tissue, or of the peripheric pulmonary parenchyma. 
This fluxion naturally carries with it into the pulmonary vesicles a serous 
exudation analogous to that of pulmonary cedema. We also meet with a 
fine subcrepitant rale, which is very often heard quite at the beginning of 
the pleurisy, and which likewise nearly always continues for some weeks, 
when the fluid being absorbed, there only remains subinflammatory oedema 
of the more superficial parts of the lungs." Perhaps this explanation may 
apply to certain cases, but there can, I think, be no reasonable doubt that 
the clicking sound to which I have alluded, since it is superficial and does 
not commonly disappear after coughing, is pleuritic. 

When the second stage commences and the pleural cavity contains 
more or less liquid, the lung, unless adherent to the ribs, is carried inward 
and upward and compressed. The respiratory sound now disappears in 
children over the age of five years, but in a large proportion of cases in 
the first years of childhood, and usually in infancy, in which period the 
pleural cavity is small, respiration is heard when the ear is applied over 
the liquid. It is transmitted through the liquid from the bronchial tubes 
or from the opposite lung. Its character is bronchial, broncho-vesicular or 
vesicular. It varies in intensity according to the amount of the liquid, 
and the strength and rapidity of the respiration. When the inflammation 
is active, and exudation occurs rapidly, bronchial respiration may be heard 
as early as the second or third, or even on the first day, when the ear is ap- 
plied in the scapular and infrascapular region. Rilliet and Barthez be- 
lieve that it differs from the bronchial respiration of pneumonia, not only 
in its duration, but also in the character of its sound, being metallic. If 
the inflammation is mild, and the exudation occurs slowly, bronchial respi- 
ration is not observed till after the lapse of some days. When there is a 
very considerable amount of liquid exudation, bronchial respiration may 
be observed in the infraclavicular region as it so often is in adult cases. 
J^gophony is occasionally noticed in cases which are attended by a large 
eflTusiou ; it coexists with the bronchial respiration. It is heard in the inter- 
and infrascapular spaces. Its duration is commonly brief, disappearing 
in three or four days, or even in less time. Feeble vesicular respiration may 
be heard in one part of the chest, while in other parts the bronchial respi- 
ration occurs, and in other parts still, namely, at the base, no sound what- 
ever is audible ; or without the bronchial respiration we may hear a distant 
or faint vesicular murmur over the entire half of the chest, which is the 
seat of the disease. Such are the various combinations and modifications 
of the respiratory sounds noticed in these cases, sounds which present vari- 
ations in their presence and relative proportion as the disease advances. 

Percussion. — Percussion in the commencement of pleuritis before there 
is any appreciable exudation gives a negative result. If dulness is ob- 
served, it is due to coexisting disease, commonly pneumonitis or tubercu- 
losis. When exudation occurs, unless it is entirely fibrinous, percussion 



INSPECTION — MENSUHATION. 539 

over the affected side gives at first a dull and then a flat sound, but above 
the level of the liquid the resonance is good, and occasionally tympanitic. 
The sensation communicated to the finger in percussing, is like that pro- 
duced by a solid substance. The flat percussion-sound distinguishes the 
pleuritic exudation from the solidification of pneumonitis, for the percus- 
sion-sound in pneumonitis is dull, but not flat. In young children, in 
whom pneumonitis is catarrhal, and limited to a part of a lobe, the dif- 
ference is very marked. Changes in the height of the flatness according 
to the position of the patient is sometives observed in infancy and child- 
hood, but this sign is less reliable than in adult life. Now and then we 
observe cases in which other physical signs do not indicate the presence of 
a liquid in the pleural cavity, and there is no pulmonary disease, and yet 
percussion gives a dull sound. In these cases the dulness is due to the 
fibrinous exudation, which often has a very considerable thickness, espe- 
cially if its fibres are loosely arranged. I have related above a case in 
which the exudation was three-fourths of an inch thick. If the pleuritis 
depends upon tuberculosis or pneumonitis, the physical signs which charac- 
terize the primary disease are intensified by the exudation. 

Inspection — Mensuration. — At first, if respiration is painful the 
movements of the affected side in breathing are somewhat restrained, and 
subsequently when there is a large effusion they are more limited than on 
the opposite side. 

Bulging of the intercostal spaces, and distension of the thoracic walls 
from the fluid, are less frequently observed and less marked in young chil- 
dren than in adults. In the infant, especially if feeble, so readily are the 
lungs compressed, complete carnification is apt to occur before the shape of 
the chest is materially altered. "When there is a large pleuritic exudation 
with bulging of the intercostal spaces the circumference of the chest on the 
affected side is rarely more than three-fourths of an inch to one inch 
greater than that of the healthy side. 

On account of the peculiarities as regards the physical signs and the 
mechanical effect of a liquid in the pleural cavity of a young child, phy- 
sicians whose knowledge of pleuritic effusions is derived chiefly from the 
examination of adult cases are apt to err in diagnosis. Thus, in 1870 a 
carnified lung, covered with a thick pyogenic membrane from which gran- 
ulations had arisen, was presented by myself to the New York Pathologi- 
cal Society, with the following history of the case. W., twelve months old 
at the time of death, was taken sick at the age of six months, with fever, 
and a cough, which was slight and not frequent. At about eight months 
he first came under observation. The infant was then small for its age, 
pallid and thin. The two sides of the chest measured the same, and on 
both sides the intercostal spaces were somewhat depressed, but percussion 
over the right side produced a flat sound, showing that the air was wholly 
excluded from the right lung. The respiration upon the affected side was 



540 PLEUEITIS. 

bronchial and distinct. Two well-known physicians of this city, thorough 
in their examinations, and usually accurate in diagnosis, examined this 
ease in reference to the propriety of thoracentesis, and both expressed a 
decided opinion that the pathological state was not a pleuritis, but either 
collapse or interstitial pneumonitis, one of them observing, as he thought, 
in addition to the physical signs already stated, bronchophony. The febrile 
movement was moderate, and no decided hectic was observed. Death oc- 
curred from exhaustion. At the autopsy about half a pint of thick pus 
was found in the right pleural cavity, producing complete caruification of 
the lung. The pus, which, considering the stunted growth of the child and 
small size of the pleural cavity, was considerable, had evidently lost a con- 
siderable part of the liquor puris by absorption. 

The following case, which shows how deceptive the physical signs may 
be in young children in cases of suppurative pleuritis, will repay perusal, 
since the life of the patient depends in gx'eat part on a correct understand- 
ing of his condition, so that appropriate measures will be employed : 

Case. — H , boy, four years four months old, was taken with scarlet 

fever in the latter part of May, 1868. It was severe, and was attended 
with inflammation of the glands and connective tissue of the neck, with 
suppuration on both sides. Purulent discharges from the abscesses contin- 
ued through the month of June. The patient was gradually convalescing, 
when, about July 4th, pleuritis commenced on the left side, attended by 
the ordinary symptoms of acute forms of this inflammation. A few days 
subsequentlv the pleural cavity was ascertained by examination to be about 
half full of' liquid. 

Towards the close of July anasarca commenced about the ankles and 
gradually extended upwards. It was limited to the lower extremities and 
to the abdominal walls, and by the middle of August became excessive. 
The thoracic walls and the upper extremities were somewhat emaciated, 
and the face was pallid and anxious. 

On the 7th of August a careful examination of the chest was made iu 
reference to the propriety of thoracentesis. The intercostal spaces on the 
left side were not prominent, but rather depressed. Percussion over the 
lower third of the left pleural cavity elicited a flat sound, while above 
this the resonance was tympanitic. On account of the great restlessness 
of the patient, no useful information was derived from change of position. 
On auscultation distinct bronchial respiration was heard over nearly or 
quite the entire left side of the chest. The apex beat of the heart was on 
the right of the sternum. It was my opinion, as well as that of two other 
physicians, that the liquid was in process of absorption, and that the quan- 
tity present was not large. Thoracentesis did not, therefore, seem a proper 
measure. 

The anasarca still limited to the lower extremities, and the abdominal 
walls continued to increase, and on the 25th of August, so great was the 
distension, that the skin broke in one or two places above the ankles. 
The mind remained clear and the appetite was pi'etty good. Death oc- 
curred August 27th. 

Sectio Cadaver. — Head not examined ; abdominal and right pleural 
cavities contained no eflTusion, and were iu their normal state, except that 



DIAGNOSIS. 541 

the latter cavity was somewhat encroached upon by the heart and medi- 
astinum ; a great amount of oedema in the k>wer extremities and in the 
abdominal walls ; abdominal walls towards the spine about three inches 
thick, in consequence of oedema ; right lung of good size and presenting 
the ordinary appearance, except a greater amount than usual of hypostatic 
congestion ; about three pints of pus (laudable) in the left pleural cavity ; 
left lung completely carnified and lying against the vertebral column ; its 
size about that of an orange, and its surface covered Avith a dense layer of 
fibrin ; heart displaced, as already stated, to the right and a little down- 
Avard, so as to compress and partially obstruct the circulation in the 
ascending vena cava ; this vessel contained a continuous, firm, and yellow 
fibi'inous clot, nearly filling its calibre; the femoral vein, examined on 
one side, was found to contain soft and dark clots. Compression of the 
cava opposite the heart and the formation of clots had evidently given 
rise to the anasarca. 

An important negative sign, as we will see, is the absence of bron- 
chophony and vocal fremitus over that portion of the chest where the 
liquid has accumiilated. 

Occasionally physical signs, Avhich commonly indicate tuberculosis, are 
heard in children as well as adults on auscultating the chest which is the 
seat of a pleuritic attack. Attention has been called to this fact by Killiet 
and Barthez, one of Avhora bad diagnosticated tuberculosis from these 
signs, in a case which fully recovered, and afterwards by Trousseau, who 
says : " In cases of pleurisy we often meet with all the stethoscopic signs 

which belong to the third stage of tubercular phthisis Amphoric 

respiration, gurgling, and cavernous voice are sometimes so well marked, 
that it is impossible to avoid attributing them to the existence of cavities 
in the lungs." The occurrence of these signs, however, in uncomplicated 
pleuritis is rare, but it is necessary to be aware of their occasional occur- 
rence, in order that the diagnosis in cases in which they are observed be 
more careful and guarded. 

It has been said by certain writers that displacement of the heart and 
the subdiaphragmatic organs by large pleuritic effusions is less frequent 
and less in degree in children than in adults. However this may be, it is 
certain that displacement of the heart to the right is common in pleurisy 
of the left side, even when the quantity of liquid in the pleural cavity is 
moderate. I have found this fact very useful in diagnosis. 

Diagnosis. — This is in certain cases readily made, but in other instances 
is, as we have seen, attended with difficulty. Obscure or doubtful cases 
occur chiefly in infancy. Partial or circumscribed pleuritis, attended 
with little or no serous exudation, is more apt to be overlooked than other 
forms of the inflammation, but, as it is ordinarily due to grave disease 
of the lungs, Avhich requires the chief treatment, its detection is not very 
important. The points involved in its diagnosis are acceleration of pulse 
and respiration, increase of temperature, expiratory moan, friction-sound, 
and tenderness on percussion. 



542 PLEURITIS. 

The diagnosis of acute general pleuritis in its corameucemeut, before the 
stage of effusion, is attended with some difficulty. It is most likely to be 
mistaken for pneumonitis, since the prominent symptoms in the commence- 
ment of the two diseases are similar. There is, however, in pleuritis 
ordinarily greater acceleration of pulse and respiration, greater elevation 
of temperature, greater suffering, as indicated by the features, and a more 
decided expiratory moan. It will aid in the differential diagnosis, in 
children under the age of five years, to recollect that acute pneumonitis 
is in most instances preceded by bronchitis, which is not the case with 
acute pleuritis, except as a coincidence. 

Pleuritis with effusion could only be mistaken for pneumonitis or hydro- 
thorax. But the loss of resonance on percussion in cases of pleuritic effu- 
sion is much gi'eater than when the lung is solidified from pneumonitis. 
The physical signs, which are involved in the differential diagnosis of 
these diseases in the adult, are important, also, for diagnosis in children, 
though, as we have seen, they are less constant and less reliable in young 
children than in adults. In children over the age of five years they are 
pretty uniformly present. The signs alluded to are bulging of the inter- 
costal spaces, expansion and subsequently retraction of the chest, evidence 
of change in the height of the fluid by change in the position of the 
body, no bronchophony and fremitus as in pneumonitis, etc. The absence 
of bronchophony and vocal fremitus, as evidence of a liquid in the pleural 
cavity, needs to be emphasized. These physical signs maybe observed in 
pleurisy, even when there is considerable effusion, provided that the ex- 
amination is made over a point where the lung happens to be adherent to 
the ribs, but if it is made over the liquid they will not be observed. The 
presence or absence, therefore, of these signs aid materially in the diag- 
nosis between a liquid and solidification of the lung. Hydrothorax in 
the child commonly results from one of the eruptive fevers, especially 
scarlatina, and its immediate cause is nephritic congestion or inflamma- 
tion, or heart disease. Rarely it is due to obstruction in the pulmonary 
circulation, in consequence of enlarged bronchial glands. It is not, there- 
fore, preceded nor accompanied by symptoms of inflammation referable 
to the chest, as in cases of pleuritic eftusion. 

Empyema may be diagnosticated from the fact that there is but little 
diminution in the amount of liquid after several weeks have elapsed, and 
from the febrile movement, loss of appetite, flesh, and strength, which 
attend all large purulent collections. 

Prognosis. — Primary pleuritis, occurring in patients previously healthy, 
commonly ends favorably ; but it is a serious disease if the general health 
has been much impaired. The prognosis is moi'e favorable if, as is com- 
monly the case with this form of pleurisy, the patient is over the age of 
three or four years. 

Secondary i)leuritis is, on the other hand, a grave affection, but the 



TREATMENT. 543 

prognosis depends greatly on the character of the primary malady, and 
also on the age. Pleurisy resulting from and coexisting with pneumonitis 
commonly ends favorably even in quite young patients. Pleuritis arising 
from scarlet fever is apt to be suppurative, and is, therefore, a serious com- 
plication or sequel, but a considerable proportion affected Avith it recover 
under judicious treatment. The prognosis in tubercular pleuritis and 
pleuritis occurring from the escape of pus into the pleural cavity is obvi- 
ously unfavorable. 

Tubercular pleuritis may- be temporarily relieved, but it is apt to return. 
Suppurative pleuritis, or empyema, is also an unfavorable form of inflam- 
mation, characterized by the chrouicity and many of the symptoms of 
tuberculosis. It is in time fatal unless the pus is evacuated. On the 
escape of the pus, whether spontaneously or by thoracentesis, there is 
usually progressive and complete restoration to health. In case the pus 
is evacuated, the prognosis is better in children than in adults. 

Treatment. — The indications of treatment are, in the commencement 
of the inflammation, to diminish its intensity, and relieve pain ; at a later 
period to promote absorption and sustain the vital powers. 

Pleuritis is one of the few inflammations in early life in which the ab- 
straction of blood may be proper. It may be stated as a rule, that loss of 
blood is not only not required, but is an injudicious measure in all secon- 
dary pleurisies, and in the primary form after exudation into the pleural 
cavity has occurred. It is a useful measure at the commencement of 
acute primary pleuritis occurring in a robust state of system. One or two 
leeches should be applied directly over the seat of the inflammation, and 
bleeding may be encouraged for two or three hours subsequently by the 
application of cloths wrung out of warm water. Unfortunately the phy- 
sician is, in many cases, not called at this early period ; or, if called, he 
fails to make the diagnosis till there are evidences of exudation. 

After bleeding has ceased, or in subacute and secondary pleurisies with- 
out the employment of leeches, a large rubefacient cataplasm should be 
applied over the affected side of the chest, and covered with oil-silk. A 
poultice consisting of one part of mustard and sixteen of flaxseed between 
two pieces of thin muslin and sufficiently wet answers the purpose. 
Moderate counter-irritation diminishes the pain, but vesication at this 
early period is injurious. A blister applied so near the seat of the in- 
flammation may increase the afflux of blood towards it, and aggravate the 
disease. 

Robust patients over the age of three or four years, are benefited by the 
use of cardiac sedatives in the commencement of acute pleuritis. The ' 
tincture of aconite root should be given, but its effects should be watched, 
and it should be discontinued or given less frequently when the pulse is 
reduced to nearly the natural number, or when sufficient exudation has 



544 PLEURITIS. 

occurred to produce the ordinary physical signs of liquid in the chest. 
It should be given cautiously in secondary pleuritis. 

Opiates are required, as in other serous inflammations, according to the 
pain. Dover's powder, in doses of one to three grains, according to the 
age, may be given every two or three hours, or less frequently if the patient 
is inclined to sleep. 

The following is a favorite prescription with me for a child of three 
years : 

R. Tine, ipecac, comp. 

(Squibb's liquid Dover's powder), gtt. xvj-xxiv. 
Tine. rad. aconit., gtt. viij. 
Syr. bal. toiut., ^ij. Misce. 
Dose, one teaspoon ful every two or three hours. 

Such is the treatment required in the first stage of acute primary pleu- 
ritis, or that preceding the effusion. Secondary pleuritis requires fewer 
and less depressing measures. The appropriate treatment, in a larger pro- 
portion of the cases of this form of the disease, consists in the use of an 
opiate, with rubefacient and emollient applications to the chest. Abstrac- 
tion of blood is not required in this form of pleuritis, but the aconite is 
sometimes useful for a few days. 

Pleurisies dependent on pulmonary disease, which are circumscribed and 
attended with little serous effusion, i-equire no other therapeutic measures 
than those already mentioned. The judicious use of opiates, and rubefa- 
cient and emollient applications, suffice for their treatment. 

In the treatment of other forms of pleurisy, which are attended by more 
or less efl^usion of liquid into the pleural cavity, measures designed to re- 
move this liquid are required when the inflammation has abated, and 
autiphlogistics are no longer appropriate. 

Liquids iu the great cavities are best eliminated by hydragogue cathar- 
tics and by diuretics. For children, however, already weakened by pleuritic 
inflammation, cathartics are usually too depressing. Now and then a robust 
patient, over the age of five or six years, with pleuritic effusion, may be 
benefited by an occasional purgative dose of bitartrate of potassa, or by from 
one-twelfth to one-sixth of a grain of podophyllin. But such cases are ex- 
ceptional. In a majority of children the loss of strength resulting from 
cathartics more than counterbalances the good result from the liquid 
evacuations which they produce. 

Diuretics, on the other hand, are efficient remedies, and upon them our 
'chief reliance must be placed. 

The diuretic from which I have seen better effects than from any other 
is iodide of potassium, but it should be given in large doses. In the adult 
I have observed rapid absorption of the liquid by the administration of 
from one to two drachms daily of this agent, given in doses of ten grains. 



TREATMENT. 545 

and a child can lake a proportionate dose. Two to five grains, according 
to the age, may be given every three hours. At the same time it is ad- 
visable to restrict the drinks. 

At this stage of the disease counter-irritation is appropriate, either by 
rubefacients or vesicants. The preferable mode of blistering the child is, 
in my opinion, by cantharidal collodion applied as recommended in the 
treatment of pneumonitis, I prefer, however, instead of vesication, the 
application by friction two or three times daily of the unguent iodini com- 
positi of the Pharmacopoeia. ^ 

In secondary pleuritis the diet should be nutritious, consisting largely 
of animal broths, through the whole period of the disease. 

In primary pleuritis nutritious diet should be allowed after exudation 
has occurred. In some cases, more frequently in secondary than primary 
pleuritis, stimulants are required. In protracted pleuritis, or pleuritis oc- 
curring in a debilitated patient, tonics, both vegetable and chalybeate, are 
often serviceable, sustaining the strength while the process of absorption is 
going on. 

Occasionally the measures which have been recommended above to pro- 
mote absorption of the liquid in the pleural cavity do not have the effect 
which is desired. If there is no sensible diminution in its amount, and if 
the general health of the patient begins to fail, the performance of thora- 
centesis should be considered. We may accomplish by surgery what we 
fail to do by therapeutic means. 

Thoracentesis is one of the oldest operations in surgery, having been prac- 
ticed by the school of Hippocrates, and being described in the writings of 
Galen, but till a recent period it was only performed in rare instances, and 
then hesitatingly as a last resort. " During the middle ages," says Trous- 
seau, " it was discussed whether it were better to make the opening into 
the chest by steel or by fire, and the operation was rarely performed, ex- 
cept in surgical lesions." It was reserved for Trousseau between 1843 
and 1847, to convince the profession, amid considerable opposition, not 
only of the safety, but of the urgent need of the performance of thoracen- 
tesis in cases not only of purulent exudations, but also in many cases of 
extensive serous or sero-fibrinous exudations into the pleural cavity. By 
a series of cases he was able to show the great risk in deferring the opera- 
tion, when there is a large and increasing effusion which does not yield to 
remedial measures, for orthopnoea suddenly developed may carry off the 
patient. 

ExcejDt Trousseau, Dr. Bowditch, of Boston, has done more than any 
other physician to remove all existing prejudices against thoracentesis, and 
bring it into vogue. His statistics, as they are the most numerous, are tlie 
most satisfactory and convincing yet published. Previously to 1870 he 
had performed this operation " 250 times in 154 persons, without once see- 
ing any evil, or even any very distressing symptoms resulting from it, while 

35 



546 PLEUEITIS. 

on the other haud it has saved a large number of lives, that must other- 
wise have been sacrificed." Statistics show that thoracentesis, for the re- 
moval of pleuritic effusions, results favorably in a larger proportion of cases 
in childhood than in adult life. In my own practice during the last five 
years, this operation has been performed upon seven children with empyema, 
the result, in all instances, of the operation being favorable, except in one, 
in which there were, no doubt, tubercles, while during the same time in at 
least two instances, I have observed children perish of empyema without 
the operation. 

One of the chief reasons why thoracentesis was formerly so seldom per- 
formed, was the dread of admitting air into the pleural cavity. It was 
thought that the contact of air with the pleura in cases of empyema caused 
a continuance or aggravation of the suppurative inflammation, effected a 
decomposition of the pus, and gave rise to the formation of noxious gases 
within the chest, which increased the cachexia and depression of the pa- 
tient. No doubt the contact of air tends to promote purulent decomposi- 
tion, but if the pus is removed by the operation, as it should be, or if the 
opening remains fistulous, no harm results in a case of empyema from the 
admission of a moderate quantity of air, except so far as it prevents ex- 
pansion of the lungs. Any possible ill effect from pus decomposition can 
certainly be prevented by washing out the pleural cavity with tepid water, 
to which a little carbolic acid is added. At the present time, I think, the 
profession generally agree that the entrance of a moderate amount of air 
into the pleural cavity in cases of empyema, does little or no harm, but 
there is a general apprehension that it may convert a sero-fibrinous into a 
suppurative pleuritis. The evil effects of the admission of air have evi- 
dently been misunderstood. Surgeons are not deterred from the removal 
of ovarian tumors by the fear of admitting air into the peritoneal cavity, 
and why its admission into the pleural cavity has been and is so much 
dreaded, it is difficult to understand. In the London Lancet, January 15th, 
1831, the case is related of a man Avho suffered from heart disease, and 
was led to think that the pressure of a small quantity of air internally 
might be substituted for external pressure, which always gave relief. The 
idea occurred to himself, and he was his own operator. He employed a 
fine tube about as slender as a common pin, to which a bladder was at- 
tached containing common air. The point of this was thrust through the 
skin and subcutaneous tissues till it reached the cavity, and air was squeezed 
through it by compressing the bladder. Relief always followed, and im- 
provement was effected in the patient's health. These experiments were 
continued two or three years. Dr. Lizars, who was present at the meeting 
of the medical society before which this case was related, stated that he 
had performed this operation on four or five patients affected with aneur- 
isms, with some apparent benefit, and in no case with injury. 

In view of such facts it seems probable that the admission of a little air 



TREATMENT. 547 

into the pleural cavity during the oiDeration of thoracentesis can do little 
harm, whether the exudation, for the removal of which the operation is 
performed, is sero-fibrinous or purulent. However, with the mode of oper- 
ating which is now commonly employed, namely, by the aspirator, the 
admission of air is prevented. It is jDrobable, also, that some of the preju- 
dice against thoracentesis resulted from the improper manner in which the 
operation was performed, and the faulty instruments employed previously 
to the last thirty or thirty-five yeai's. Surgeons previously to this time 
advised puncturing in the anterior a'fepect of the chest, instead of in the 
well-known eligible point, under the angle of the scapula. 

It is very important to be able to determine the circumstances under 
which thoracentesis should be performed. Dr. Anstie, in his article on 
pleurisy, in Reynolds's System of Medicine, lays down the following judicious 
rules for determining when to operate : 

1. In all cases of pleurisy, at whatever date, where fluid is so copious as 
to fill one pleura, and begin to compress the lung of the other side ; for in 
all such cases there is the possibility of sudden and fatal orthopnoea. 

2. In all cases of double pleurisy, when the total fluid may be said to 
occupy a space equal to half the united dimensions of the two pleural 
cavities. 

3. In all cases where the efl^usion being large, there have been one or 
more fits of orthopnoea. 

4. In all cases where the contained fluid can be suspected to be pus, an 
exploratory puncture must be made ; if purulent the fluid must be let out. 

5. In all cases where a pleuritic effusion, occupying as much as half of 
one pleural cavity, has existed so long as one month, and shows no sign of 
progressive absorption. 

The simplicity and almost painlessness of the operation is an argument 
in favor of its early performance, even in certain cases which might and 
probably would eventuate favorably with only medicinal measures, for the 
evacuation of the liquid will often greatly shorten the disease, and relieve 
the patient of much suffering. American physicians have not yet learned 
to operate as early as some of our transatlantic brethren, and there is no 
doubt more danger of our deferring the operation too long, than of opera- 
ting at too early a period. Murchison tapped the chest of a boy, aged 
seven years, on the twelfth day of acute pleuritis, removing twenty-four 
ounces of nearly transparent serum, with the entrance of some air into 
the pleural cavity. The effusion had displaced the heart, and caused 
slight dyspnoea and Aveakness of pulse. The patient did well, and in one 
month fully recovered. 

If the exudation is purulent, unless the quantity is very small, the physi- 
cian is indeed censurable if he defers tapping, for there is every proba- 
bility that the state of the child will become daily worse, from the in- 
creasing cachexia, and the retention of pus in the system endangers the 



548 PLEURITIS. 

formation of tubercles. (Art. Tuberculosis.) Cases like the following, 
•which perhaps an early resort to tapping might relieve, are not in my 
opinion very infrequent. In the latter part of November, 1873, I was 
asked to see an infant, aged 12 J months, who had pleuritis of the right 
side, commencing a few days previously. During December the tempera- 
ture was usually from 101° to 101f°, and pulse from 140 to 160 per min- 
ute. The physical signs indicated a small amount of liquid, no doubt 
purulent, in the inferior and posterior part of the right pleural cavity, and 
adhesion of the right lung laterally and anteriorly to the walls of the 
chest. The amount of liquid seemed so small, that it was deemed best, in 
consultation, to defer the operation, although there was progressive loss of 
flesh and strength. A few weeks subsequently, the symptoms and physi- 
cal signs indicated the formation of tubercles, and early in the following 
spring death occurred. 

On the other hand we sometimes meet cases in which there is consider- 
able liquid effusion, with but little dyspnoea, loss of appetite, and consti- 
tutional disturbance. Under such circumstances, the general condition 
being good, thoracentesis may ordinarily be safely deferred. Medicinal 
agents may, and probably will, suffice for the cure. 

The site of the puncture may be ascertained by the rules of Dr. Bow- 
ditch : "Find the inferior limit of the sound lung behind, and tap two 
inches higher than this on the pleuritic side, at a point in a line let fall 
perpendicularly from the angle of the scapula. Push in the intercostal 
space here with the point of the finger, and plunge the trocar quickly in 
at the depressed part ; be sure to puncture rapidly and to a sufficient depth, 
or you may be balked by the false membrane occluding the canula." An 
eligible point for the operation is from one to two inches below the angle 
of the scapula, either upon the line drawn vertically through that angle 
or a little inside or outside of that line. 

Having selected the point for the puncture, the hypodermic syringe 
should be introduced, and by slowly withdrawing the piston, we are able 
to ascertain the nature of the liquid, for even if it be very thick pus, a few 
drops will enter the instrument. If it be mainly serous, and we desire to 
remove it, it may be allowed to drip from the instrument, or it may be 
removed through the small point of the aspirator. If it be pus, it can be 
removed by employing the medium-sized point of the aspirator, or by es- 
tablishing a fistulous opening, with a narrow bistoury introduced close to 
the upper edge of the rib, the skin being drawn up a little with the finger. 
By either operation children ordinarily do well, though their restoration 
to complete health may be slow. The following case is interesting as show- 
ing a favorable result, from opening the chest with a bistoury in an infant, 
that seemed almost moribund at the time of the operation, and whose 
death had been predicted by experienced physicians. December 8th, 1873, 
Mary B., aged 5 months, nursing, inmate of New York Infant Asylum, 



TEEATMENT. 549 

has had a cough for three weeks, but it has been more frequent and severe 
during the last three or four days than previously. Is pallid and weakly- 
looking. 

Dec. 12th. Pulse, 120 per minute ; temperature, 100f° ; has flat percus- 
sion-sound over the entire left side of the chest, and a pleuritic, clicking 
sound, is observed in the left scapular region ; respiration slightly ab- 
dominal, and accompanied by an expiratory moan; respiratory murmur on 
left side distant, and broncho-vesicular or bronchial ; no appreciable bulg- 
ing of intercostal spaces on this side ; circumference of left side of chest 
from half to three-fourths of an inch greater than that of opposite side ; 
he is gradually losing strength ; and his features are pallid, and of a flabby 
appearance, notAvithstanding the constant use of stimulants and tonics. 
Dec. 15th. Pulse, 144; temperature,, 100°. Dec. 22d. Pulse, 168 ; tem- 
perature, 991°. Dec. 26th. Pulse, 160 ; temperature, 101^°. Dec. 29th. 
Pulse, 144; temperature, 99i°. Jan. 8th, 1874. Pulse, 156; respiration, 
60 ; temperature, 101°. On this day (January 8th) the presence of pus 
in the pleural cavity having been ascertained by the hypodermic syringe, 
an incision was made through the walls of the chest with a narrow bis- 
toury, about one and a half inches below the angle of the scapula. Thin 
pus, tinged with blood, perhaps two ounces, escaped, and some air entered 
the chest during the operation. The opening remained fistulous, discharg- 
ing pus, which was often unhealthy-looking and offensive, with intermis- 
sions of a day or two, till about the middle of June, when the flow ceased, 
and she has since remained well. 

I prefer, however, in general, the use of the aspirator for the removal 
of pus in the empyema of children. The removal of all the pus, which 
can be aspirated at a single sitting through an aspirator point of medium 
size, will ordinarily, I think, be sufficient to insure a favorable result, as in 
one of the cases detailed above ; for, though there is some pus remaining, 
it will be absorbed, provided that the quantity is not too large. Washing 
out the pleural cavity with tepid water, to which a little carbolic acid is 
added, no doubt expedites recovery. It is especially useful when the pus 
is fetid, as in the case last related. If the child do not progressively im- 
prove, or if the physical signs indicate a refilling of the cavity with pus, 
I would then establish a fistulous opening. Thus, in the case of a child 
aged about three years, who was brought to my clinique at Bellevue in the 
spring of 1875, Dr. Ackerman and myself removed about eighteen ounces 
of pus by aspiration. There was great relief, but a few weeks subsequently 
it was brought back with symptoms and physical signs almost as grave as 
at first, when the Doctor judiciously established a fistulous opening, after 
which the case progressed favorably. 



550 PLEURITIS. 



Nervous Cough. 



A nervous cough sometimes occurs iu children, especially between the 
ages of two or three and ten years. It may result from disease of the 
brain, from the second as well as first dentition, from some irritant in the 
intestines, as worms, and also from spinal initation. Occasionally there 
appears to be no local cause, but a state of anremia, or a highly developed 
nervous temperament, to which it seems proper to ascribe the cough. 
OccuiTrng under these last circumstances it corresponds with, and is some- 
times accompanied by, functional disturbance iu the action of the heart, 
as palpitation. 

A nervous cough is short, painless, and without expectoration. It usually 
attracts little attention at first, but from its long duration the friends finally 
become anxious lest it betoken some serious disease. At times it may nearly 
subside if the patient lead a quiet life and the general health improve, and 
there are j^eriods of recrudescence if the opposite conditions obtain. It may 
have a spasmodic character especially in times of mental excitement, but 
in a less degree than the cough of pertussis. If not properly treated it 
usually continues several weeks or months, disappearing as the general 
health and the tone of the nervous system improve. It is not in itself a 
serious disease, nor does it lead to any ailment or produce any injury of 
the respiratory organs, but it is an unpleasant malady, and is liable to be 
mistaken for incipient tuberculosis if it occur in one decidedly cachectic, 
and belonging to a family predisposed to phthisis. 

Treatment. — If there is a local cause of the cough, measures calculated 
to remove this, or at least to palliate its effects, are obviously required. 
Especially should constipation, or any abnormality in the digestive func- 
tion be corrected. But in many cases there is no apparent local ailment 
which produces the cough by its irritative effect, and the remedial measures 
must then be twofold, namely, measures designed to improve the general 
state, and secondly, measures designed to relieve the cough. Such meas- 
ures are also required in most cases in which there is a local cause, pro- 
vided that the cough do not cease when treatment calculated to remove 
this cause has been employed. 

For constitutional treatment no remedy is so useful in ordinary cases as 
iron. The following example shows the benefit which may result from the 
use of this agent, since in this case it affected a cure without the aid of 
other measures. B , aged 11 years, pallid and of spare habit, but ac- 
tive, and with good api^etite, had been treated for this malady by different 
physicians but without improvement. His mother had died of tuber- 
culosis, and some at least of the physicians believed that he was in the 
commencement of the same disease. Finally he was placed under the 



TREATMENT. 551 

care of the late Dr. Cammann, who, detecting the nature of the malady, 
wrote the following prescription : 

R. Ferri. subsulphat., ^ss. 
Acid, nitric, f^ss. 
Aq. destillat., gss. Misce. 
Dose, tliree drops four times daily in sweetened water. 

The cough disappeared in a surprisingly short time. If the appetite is 
poor the vegetable tonics are required in combination with iron. 

If the cough is frequent and troublesome, medicines which exert a 
direct controlling effect upon it are required in addition to the medicines 
and measures employed to improve the general state. For this purpose 
no remedy is so useful as the bromides, employed alone or in combination 
with belladonna. If there is no decided aneemia, and no local cause of the 
cough, the bromides and belladonna usually effect a cure without the em- 
ployment of constitutional measures, or if the case seem to require iron it 
may be given in the interval. The following is the prescription for a child 
of three years : 

R. Tine, belladonna, gtt. xxxij. 
Potas. bromid. 
Ammon. bromid., aa ^j. 
Syr. simplic, ^ij. Misce. 
Dose, one teaspoonful twice daily. 

In 1871 I was asked to prescribe for a German boy, aged 8i years, who 
had a cough of this kind of two months' duration, which latterly had been 
frequent and annoying. Within a week he was entirely relieved without 
other remedy, by the employment of tincture of belladonna, drops v, and 
bromide of ammonium, gi'. v, twice daily. Outdoor exercise, or country 
residence and other regimenal measures which, improve the general health 
are useful in ordinary cases. 



SECTION III. 

DISEASES OE THE DIGESTIVE APPARATUS. 



CHAPTER I. 

SIMPLE STOMATITIS; ULCEROUS STOMATITIS; FOLLICULAR 
STOMATITIS. 

Diseases of the digestive system iu infancy and childhood are of fre- 
quent occurrence. They are for the most part readily recognized, and are 
more easily and quickly controlled by therapeutic agents, if rightly ap- 
plied, than are the diseases of any other system. If misunderstood and 
improperly ti-eated, they may, even when mild and very manageable in 
their commencement, become chronic and obstinate, or even fatal, or they 
may lead to other and more dangerous diseases. It is necessary, then, 
that the physician should understand thoroughly the pathology as well as 
therapeutics of the digestive system, that he may make timely and correct 
use of the required remedies. 

The diseases of the buccal cavity in early life are for the most part in- 
flammatory. The mildest is that known as 

Simple or Erythematic Stomatitis. 

This form of inflammation occurs usually before the completion of first 
dentition, and it is most frequent under the age of one year. Giving rise 
in itself to no severe symptoms, and often being connected with other grave 
and dangerous maladies, it is, doubtless, in many cases overlooked. It is 
sometimes confined to a portion of the buccal surface, or is more intense 
in one part than in another. In other cases the stomatitis is uniform, or 
nearly so, affecting the entire cavity of the mouth. 

Causes. — The common cause of simple stomatitis in infants is the same 
as that of most cases of gastro-intestinal inflammation at that age. This 
is the use of indigestible and therefore irritating food, uncleanliness, per- 
sonal and domiciliary ; in fine, all those agencies which impair the general 
health, and enfeeble the digestive organs. Therefore, stomatitis, like en- 
tero-colitis, is more common in the city than in the country, and among 



SYMPTOMS — APPEARANCES — TREATMENT. 553 

the city pooi* than those in the better walks of life. Infants deprived of 
the mother's milk and given a diet which, with all care of preparation, is 
a poor substitute for the natural aliment, are very liable to this disease, 
Beaumont ascertained from his experiments on St. Martin that irritative 
changes produced in the stomach by indigestible substances were soon fol- 
lowed by similar changes in the buccal raucous membrane. Since in young 
infants any kind of artificial food is less digestible than the breast-milk, 
it is evident why those who are prematurely weaned or are carelessly fed 
are so liable to stomatitis. This inflammation is also sometimes due to 
irritating substances taken in the mouth, as drinks habitually too hot or 
too cold. Stomatitis is also present in measles and scarlet fever. It then 
corresponds with the cutaneous eruption, and disappears when that sub- 
sides. 

Another cause is dentition. The gum over the advancing tooth first 
becomes inflamed, and, other causes perhaps conspiring, the inflammation 
extends over more or less of the buccal surface. When due to dentition 
the stomatitis is more apt to be partial than when it arises from a consti- 
tutional cause. Mercury, in whatever form introduced into the system, 
excreted from the salivary glands, and flowing over the buccal surface, is 
an occasional though nowadays rare cause. 

Symptoms — Appearances. — Stomatitis, like other mucous inflamma- 
tions, is characterized by increased redness and more or less thickening of 
the inflamed buccal membrane, by rapid proliferation and exfoliation of 
epithelial cells, and by an increased functional activity of the muciparous 
follicles. The heat of the mouth is sometimes augmented in an apprecia- 
ble degree. The gums in severe cases are swollen and spongy, and bleed 
easily if rubbed or pressed. The tongue is usually covered with a light 
fur, and the salivary secretion is augmented to such an extent sometimes 
as to dribble from the corners of the mouth. Often there is little suffer- 
ing, but in other instances the patients are fretful, experience pain from 
the contact of solid food, and, if nursing, may even wean themselves from 
dread of pressure of the nipple. 

Simple stomatitis is not difficult of detection, provided attention is di- 
rected to the mouth. Inspection informs us of its presence and extent, 
A favorable termination may be confidently predicted, unless there is a 
state of marked cachexia, or a grave coexisting disease. If circumstances 
are unfavorable, simple stomatitis may terminate in a more severe form, 
as the ulcerous or diphtheritic. 

Treatment. — The physician should endeavor to ascertain the cause, 
and, if possible, should remove it by appropriate medicinal or hygienic 
measures. Sometimes no special treatment is required, as in measles or 
scarlet fever. When the primary affection terminates, the stomatitis dis- 
appears of itself. If dentition is the cause, and there is much fever and 
fretfulness, it may be advisable to scarify over the advancing tooth, and 



554 ULCEROUS STOMATITIS. 

employ such soothing aud derivative measures as are required in painful 
dentition. In these cases mucilaginous and mild astringent lotions may 
be employed. Borax is a good remedy used either with honey or water ; 
one part of borax to three of honey, or a drachm of borax to an ounce of 
water. A weak solution of alum is also a good topical remedy. With 
either of these remedies in a favorable condition of system, and without 
any serious coexisting disease, the stomatitis is relieved. 

Ulcerous Stomatitis. 

In ulcerous, or, as designated by Rilliet aud Barthez, ulcero-merabran- 
ous, stomatitis, the anatomical characters are those of severe simple sto- 
matitis, with the additional element which gives if the name by which 
it is designated. 

The inflammation usually begins upon the gums and extends along the 
buccal surface. Wherever it commences, there soon appear little white 
points underneath the mucous membrane, producing slight prominence of 
it. These points, which are inflammatory exudations, mainly fibrinous, 
gradually enlarge. Some unite and give rise to large irregular ulcera- 
tions ; others remain isolated, producing ulcers which are smaller and of 
more regular shape. There is, indeed, no uniformity as regards the size 
and form of the ulcers. In the folds of the buccal membrane they are 
apt to be elongated, while inside the lips, or where the surface is smooth, 
the circular or oval form predominates. 

Ulcerous stomatitis is usually confined to that part of the buccal surface 
which covers the gums, or is in their immediate vicinity, but in some 
instances it aflfects nearly every part of the cavity of the mouth. 

If the disease is severe, there is considerable swelling around the ulcers, 
but the swollen part is soft and cushiony, and not very tender on pressure. 
The soft and yielding nature of the swelling serves as a means of diag- 
nosis betw^een this disease and the premonitoiy stage of gangrene, since in 
the latter affection the swollen jDart is more indurated. 

If the disease grows worse, more ulcers appear; the fibrinous exudation, 
if detached, is renewed, or it becomes thicker by the formation of new 
layers. The ulcers grow deeper and wider, and their edges more vascular. 

If, on the other hand, there is improvement, the swelling subsides, the 
ulcers become more clean, their bases approach the level of the mucous 
membrane and present a granulating appearance. Finally the mucous 
membrane is reproduced. A considerable time after the ulcers are healed, 
the new membrane which occupies their site has a redder hue than the 
adjacent surface. 

Causes. — Ulcerous, like simple, stomatitis, is most frequent in the 
families of the poor. Personal uncleanliness, poor food, a residence in 
apartments dirty, humid, or in other respects insalubrious, favor its de- 



SYMPTOMS PROGNOSIS— TEE ATMENT. 555 

velopnient. In fine, a cachectic condition, however produced, is a com- 
mon predisposing cause. It frequently occurs when the system is reduced 
or enfeebled by acute diseases, as after the essential fevers and thoracic 
and intestinal inflammations. In protracted entero-colitis of infants, it is 
sometimes severe and obstinate, and a case in which this complication 
arises usually ends unfavorably. 

Occasionally several cases occur together or consecutively in the wards 
of a hospital, and this has led some observers to believe that ulcerous 
stomatitis is contagious. But its prevalence under such circumstances is 
attributable to the fact that there is a common exposure to the influences 
which give rise to the disease, just as a whole household exposed to malaria 
may be seized with intermittent fever. Difiicult dentition is also an occa- 
sional cause. 

Symptoms. — The symptoms in ulcerous stomatitis are more severe than 
in the simple form. There is more pain, more salivation, and more fret- 
fulness. The ulcerated surface is sometimes very tendei\ so that there is 
but little sleep. Drinks, unless bland and lukewarm, are painful, and, if 
the ulcers are on. the lips or the front of the mouth, the infant nurses less 
eagerly than usual, and even with reluctance, sometimes weaning itself. 
Occasionally the submaxillary glands are tumefied, hard, and tender. 
The breath has an offensive odor. In mild cases in which the stomatitis is 
of limited extent, this odor may scarcely be noticed, but in severe cases it 
is almost like that exhaled from putrid substances. The febrile movement 
is usually slight. 

Prognosis. — A favorable prognosis may be given unless the patient is 
in a decidedly cachectic condition, or there is a serious coexisting disease, 
under which circumstances the case may be protracted. If death occur, it 
is due to the cachexia, or to some pathological state quite distinct from the 
stomatitis, most frequently entero-colitis. Ulcerous stomatitis, when the 
ulcers are small and the inflammation of limited extent, is of course more 
easily cured than when it is extensive and the ulcers are large. 

This disease is very liable to return, unless the general health is good. 

Treatment. — The physician should endeavor to ascertain the cause of 
the stomatitis, and so far as possible should remove the patient from its 
influence. It is often necessary, in order to insure a speedy recovery, to 
recommend a change in regimen, especially as regards diet and cleanliness. 
If the patient live in damp, dark, and dirty apartments, the family should 
seek a better residence, and he should be taken daily in the open air. 

Tonic remedies are generally required. The ferruginous preparations 
may be advantageously given, or the vegetable tonics, or the two in com- 
bination. In selecting the internal remedies we must regard the antece- 
dent disease, if there be any, which the buccal inflammation complicates, 
and on which it depends. For that large proportion of cases in w^iich 
there is chronic intestinal inflammation, the liquor ferri nitratis with tine- 



556 FOLLICULAR STOMATITIS. 

ture of columbo administered in simple syrup will be found useful. For 
local treatment Trousseau recommends occasional applications of nitrate 
of silver or muriatic acid as a caustic, and in the intervals a wash of equal 
parts of borax and honey. 

The chloride of lime is also considerably used in Paris. It is recom- 
mended by Rilliet and Barthez. It is applied dry to the ulcerated surface 
twice daily, and in the interval the mouth is washed with simple water. 
This treatment is continued till the ulcers present a healthy appearance 
and begin to cicatrize. Then a weak solution of chloride of lime is em- 
ployed, one grain to forty-five of the vehicle. By this treatment a cure is 
usually eflfected. Bouchut prefers using chloride of lime with honey, one 
drachm to the ounce. 

But painful applications are not required. The remedy which is most 
employed in this country and in Great Britain is chlorate of potash. It 
often acts like a specific for this as well as other forms of stomatitis. It 
may be given dissolved in water with sugar, or with one of the syrups, to 
render it more palatable. The dose is from two to five grains every two 
hours. It should be allowed to run over the aflfected part, as it is believed 
to have a local action. 

R. Potass, chlorat., 3J. 
Mellis. ^ss. 
AqiiiB, gij. 
One teaspoonful every two hours. 

Of all topical remedies in common use, chlorate of potash is probably 
the most efficacious. Some physicians prefer the chlorate of soda, on 
account of its greater solubility. If this wash is too painful on account of 
the irritable state of the ulcei-s, it may be used less frequently, and borax 
applied in the interval. 

Follicular Stomatitis. 

In this form of stomatitis the inflammation is confined to the muciparous 
follicles of the mouth, or to them and the mucous membrane in their im- 
mediate neighborhood. 

Anatomical Characters. — At first there appear in the mouth minute 
papular elevations, red, hard, and tender, which continue to enlarge and 
soon become vesicular. They may now break, leaving an ulcerated sur- 
face ; but if they continue entire they become purulent, and then their 
contents are discharged. From the commencement of the papule to the 
purulent transformation the period is perhaps three or four days. 

The ulcer which occupies the site of the eruption is round, hard, painful, 
and with a vascular margin. The base has a white or grayish ajjpearance. 
The reparative process soon commences, the ulcer presents a healthy ap- 
pearance, its size is gradually diminished, and finally cicatrization occurs. 

The liquid with which the follicles are distended in the first stages of the 



CAUSES — SYMPTOMS. 557 

disease is believed to be the natural secretion somewhat modified by the 
inflammation. 

The number of ulcers is various. There are in most cases from six or 
eight to as many as twenty. They are ordinarily discrete, and one or two 
lines in diameter. The stages of the disease rapidly succeed each other, 
and the patient fully recovers in from six to eight days, but not always. 
In exceptional instances the ulcers enlarge and become confluent, or one 
or more of them assume a gangrenous aj)pearance. This indicates a faulty 
condition of the system, a vitiated state of the blood, due perhaps to some 
antedecent or concomitant disease. In these cases the ulcerative stage is 
apt to be protracted, and recovery doubtful. 

The seat of follicular stomatitis is usually the internal surface of the 
lips and cheeks, the gums, tongue, and occasionally the roof of the mouth. 
It rarely affects the fauces. Occasionally this form of stomatitis is associ- 
ated with more general inflammation of the buccal cavity. The gums 
may then be swollen and tender, bleeding if rubbed or pressed. 

Causes. — The causes are not fully ascertained. Follicular stomatitis 
has not usually in my practice occurred in so feeble a' state of system as 
has been present in ulcerous stomatitis. Billard, speaking of the aphthae 
or ulcers of this disease, says : " They are particularly to be seen in chil- 
dren who are very feeble, pale, and of a lymphatic temperament. We do 
not look for the causes of aphthse in the retention of the meconium, acidity 
of the milk, or in the predominance of acidity in the fluids of the child ; 
we attach more importance to the consideration of the original predomi- 
nauce of the lymphatic system, or rather to the remarkable predominance 
which this system acquires under the influence of bad nutrition and viti- 
ated air, which is respired in badly ventilated places in those who are 
crowded together with a number of sick children." 

Barrier considers follicular stomatitis to be allied to those gastro-intes- 
tinal diseases which are attended by turgescence of the mucous follicles, 
and he mentions among the causes habitual congestion of the buccal 
mucous membrane and, difficult dentition. In most cases probably the 
exciting cause is some derangement of the digestive organs which may 
not be appreciable. 

While simple stomatitis and stomatitis with thrush are most common 
under the age of six months, follicular stomatitis is rare at this age. It 
is most frequent during the time which corresponds with dentition, when 
there is also the most rapid development and greatest activity of the 
muciparous follicles. 

Symptoms. — The constitutional symptoms in a large jjroportion of cases 
of aplithio are slight. In twelve children affected with this disease Billard 
found the pulse from sixty to eighty beats per minute. 

The ulcers are painful, as is indicated by the cries of the cliild when 
they are pressed, and its fretfulness. Solid food and even drinks, unless 



558 FOLLICULAR STOMATITIS. 

bland and nnirritating, are badly tolerated. The salivary secretion is 
also augmented. 

In those rare cases in which the ulcer becomes confluent or gangrenous, 
the state of the patient is really serious. There is then often gastro- 
intestinal disease. The symptoms indicate prostration. The pulse is 
feeble, the countenance pallid, and the body and limbs become wasted. 

Diagnosis. — This is easy. The only disease with which it is liable to 
be confounded is ulcerous stomatitis. In the ulcerous form there is ante- 
cedent and accompanying stomatitis affecting a considerable part, if not 
the entire buccal cavity, while in the follicular form the inflammation is 
ordinarily confined to the immediate vicinity of the ulcers. The char- 
acter of the ulcers serves also as a means of distinction. In ulcerous 
stomatitis thex'e is great variety as to size and form, while in follicular 
stomatitis there is great uniformity in both these respects. The small, 
circular ulcers are characteristic of the follicular inflammation. Before 
the ulcerative stage the vesicular eruption serves to distinguish this form 
of stomatitis from other local diseases affecting the cavity of the mouth. 

Prognosis. — Follicular stomatitis usually ends favorably ; but, if the 
ulcers become concrete or gangrenous, the health is seriously aflfected, and 
a more cautious prognosis should be expressed. The unhealth}' appear- 
ance of the mouth and the real danger are often more due to the depress- 
ing eflTect of some concomitant disease than to the stomatitis. 

Treatment. — In ordinary follicular stomatitis, which is discrete and 
attended by little or no constitutional disturbance, local remedies suffice 
to cure the disease. Demulcent drinks or applications to the mouth 
should be used, as the mucilage from gum acacia, marsh-mallow, or flax- 
seed. Mild astringent lotions with the demulcent are also beneficial. 
The mel boracis is one of the best and most agreeable applications. It 
may be placed in the mouth with a spoon, or applied with a camel-hair 
pencil. If there is much tenderness of the ulcers, with restlessness, a 
small quantity of some opiate should be added to the lotion, or it may be 
administered separately. 

With this simple treatment the ulcers generally soon heal, and the 
health of the patient is restored. If, however, the ulcers are quite pain- 
ful, and not disposed to heal, or are healing tardily, they may be touched 
lightly with a pencil of nitrate of silver, or, as Barrier recommends, 
hydrochloric acid in honey of roses. This diminishes the tenderness and 
expedites the healing process. 

If, as may in rare cases occur, the ulcerations are numerous, and are 
accompanied by considerable fever, there may be symptoms indicative of 
cerebral congestion, or even premonitory of convulsions. In such cases 
laxative and diaphoretic remedies are required, and sinapisms or other 
revulsive applications to the extremities. 

If there is an unhealthy appearance of the ulcers, if they gradually 



THEUSH ANATOMICAL CHARACTERS. 559 

enlarge, or become concrete, or gangrenous, indicating a cachectic state, 
tonics should be employed with nutritious and easily digested diet, and 
anti-hygienic influences should so far as possible be removed. 



CHAPTER 11. 

THRUSH. 

The terms thrush, sprue, and muguet, the last from the French, are 
synonymous. They are used to designate a particular form of inflamma- 
tion of mucous surfaces, the peculiar feature of which is the presence of 
points or patches of a curdlike appearance on the inflamed surface. 

The usual seat of thrush is the buccal membrane, but occasionally it 
affects the faucial, pharyngeal or oesophageal. It is very rare in the sub- 
diaphragmatic portion of the digestive tube, but a few such cases have 
been reported by Billard and others. It never affects the membrane of 
the nostrils, larynx, or bronchial tubes, and it very seldom occurs in any- 
other part of the alimentary canal without also being present in the 
mouth. Thrush, then, is a stomatitis, pharyngitis, or oesophagitis, or a 
gastro-enteritis, with the additional element which I have described. 

Anatomical Characters. — The first stage of thrush is that of simple 
inflammation of the mucous surface. There next appear minute semi- 
transparent points or granules, which, increasing, soon become white and 
opaque. Some of them remain as points, while others, extending, and 
perhaps coalescing with those adjoining, form patches of greater or less 
extent. The white points or patches are unequally elevated. Their 
central part, which was first formed, is most raised, while their circum- 
ference projects but little above the epithelium. Their highest elevation 
is not ordinarily more than a line above the surface. They are smaller 
in the pharynx and oesophagus than when occurring upon the buccal sur- 
face. They resemble closely, iu color and consistence, portions of curdled 
milk, and the nurse often mistakes them for such, and neglects to call 
attention to the state of the mouth. They are readily detached by a little 
force, but are speedily reproduced. Their color in the first days of the 
sprue is white, and sometimes this color continues. In other cases they 
assume, if the disease is protracted, a yellow hue. 

Their true nature, long unknown, was finally revealed by microscopy. 
They consist in part of epithelial cells, and in part of a vegetable growth. 
This parasitic plant is in most cases the oidiuin albicans. Like other con- 
fervse, it consists of roots, branches, and sporules. The roots are trans- 
parent, and they penetrate the epithelial layer, sometimes even to the 



560 THRUSH. 

basement membrane. The branches divide and subdivide at an acute 
angle, and under the microscope they are seen to consist of elongated 
cells, with one or two nuclei. Around these branches are numerous 
sporules. In two or three instances I have examined the product of 
thrush removed from the oesophagus, and in both the parasitic plant was 
the penicillium glaucum, or a conferva closely resembling it. 

In the mildest form of thrush, this morbid product is in points or small 
patches. If the patches are of large extent, especially if, as rarely hap- 
pens, a considerable part of the buccal surface is covered by them, there 
is generally a state of great prostration and danger, from some antecedent 
or concomitant disease. Thrush is, indeed, often the sequel of some grave 
affection, as pneumonitis or gastro-intestinal inflammation. Its complica- 
tion with the last-named disease is common in young, ill-fed infants, 
especially those deprived of the breast-milk, and such cases are veiy apt 
to be fatal. 

Hence, some writers, who have observed infantile diseases in foundling 
hospitals, regard thrush as one of the most serious maladies of early life. 
Valleix, in a book of seven hundred pages relating to diseases of children, 
devotes more than one-third to the consideration of muguet. Of twenty- 
four cases, the records of which he publishes, twenty-two died, but their 
death was due to gastro-intestinal inflammation, which the author con- 
sidered a part of the more general disease, muguet. Doubtless the same 
cause which produced the stomatitis, with the confervoid growth, in these 
infants, also produced the fatal gastritis or gastro-enteritis, occurring with- 
out this growth. Nevertheless it seems better to restrict the term sprue, 
thrush, or muguet to those inflammations of mucous surfaces which are 
accompanied by the parasitic growth. I reject, then, from my descrip- 
tion of the anatomical characters of thrush, those subdiaphragmatic 
phlegmasias which some writers consider an important part of severe 
muguet, and regard them as complications, unless indeed the case is one 
of those exceptional ones in which the parasite has lodged and grown 
upon the gastric or intestinal surface. This explanation seems necessary 
in order to understand the different statements of writers in relation, not 
only to the anatomical chai-acters of thrush, but also in reference to its 
mortality. 

The frequent coexistence of thrush with gastro-intestinal inflammation, 
has been remarked in the hospitals of Europe, and in the Infant Asylum 
and the Child's Hospital, in this city. In the post-mortem examinations 
of those who have died in these last institutions, having thrush at the time 
of death or immediately prior to it, and who for the most part have been 
infants under the age of three mouths, I have frequently found evidences 
of inflammation in every division of the alimentary canal. The confer- 
void growth was, however, seldom found below the fauces, and never below 
the oesophagus. 



SYMPTOMS CAUSES — DIAGNOSIS. 561 

Symptoms. — The symptoms in thrush ai-e not different in most cases 
from those of simple inflammation. In the mildest cases they are chiefly 
of a local nature, such as have already been described in our remarks on 
simple stomatitis. If the inflammation is more extensive, especially if it 
affect the fauces and oesophagus, the infant becomes feverish and fretful, 
and the inflamed surface is hot, red, and tender. In the worst forms of 
thrush this surface not only presents the ordinary features of severe inflam- 
mation, namely heat, redness, and tenderness, but it is sometimes deficient 
in the natural secretion, so as to present a dry or parched appearance. It 
is in these cases that there is often a more extensive inflammation than 
that of the buccal or oesophageal membrane. The sub-diaphragmatic por- 
tion of the digestive tube is inflamed. In these severe cases thirst, loss of 
appetite, restlessness, vomiting, and frequently diarrhoea occur. The coun- 
tenance is anxious and pale ; there is rapid emaciation, and, if the disease 
is not arrested, a state of extreme prostration soon arrives. The twenty- 
four severe cases related by Valleix, already alluded to, twenty-two of 
which were fatal, were examples of this severe form. 

Causes. — Thrush is most apt to occur in those who are constitutionally 
feeble, or who are enfeebled by disease, or by unfavorable hygienic con- 
ditions. Cachexia is a cause common to thrush and most other subacute 
inflammations of the alimentary canal. The most obvious and common 
of the unfavorable hygienic conditions alluded to is the continued use of 
indigestible and improper food. It is, therefore, a common disease among 
foundlings, in institutions where these unfortunates are received, since they 
not only breathe an atmosphere which is often impure, but are deprived of 
the mother's milk, and are so frequently given a diet which is a poor sub- 
stitute for it. Among the poor of the cities thrush is common, since with 
them, from necessity or choice, there is the greatest neglect of sanitary 
requirements. Exposure to humidity, to variations in temperature, in- 
creases the liability to the disease, though in less degree than defective 
alimentation. Billard and Valleix agree that thrush is more frequent in 
the warm months than in the cold, that its maximum frequency is in the 
months of July, August, and September. Cases in the Infant Asylum 
and Child's Hospital, of this city, have appeared to me to correspond in 
this respect with those related by Billard and Valleix. Various writers 
have mentioned the age at which thrush is most apt to occur, as one of the 
predisposing causes. Uncomplicated thrush is not common above the age 
of six months. Most cases occur under the a^e of three months. Infants 
of the age of one or two weeks, if in addition to lactation they are spoon- 
fed by nurses over-anxious that they should thrive, are apt to take the dis- 
ease. Thrush is not uncommon in children under the age of eighteen 
months who are suffering from exhausting diseases. It is then an unfavor- 
able prognostic sign. 

Diagnosis. — This is easy so far as thrush in the mouth is concerned, 



562 THRUSH. 

for simple inspection l)y one familiar with the disease is all that is required 
in order to discover it. The presence of thrush in portions of the alimen- 
tary canal hidden from view cannot be positively ascertained. 

The vomiting, diarrhoea, pain or fretfulness, emaciation, and rapid sink- 
ing, which sometimes accompany severe forms of thrush, indicate gastro- 
intestinal inflammation, to which the attention of the practitioner should 
be chiefly directed. 

Progxosis. — The duration of thrush varies according to its intensity, 
and the favorable or unfavorable condition of the child. If it is slight 
and the health of the infant otherwise good, it may often be cured in two 
or three days. Under other circumstances it may continue as many weeks 
or even longer, before it is entirely removed. 

When thrush occurs in connection with gastro-enteritis, the mortality is 
very great. It has been already stated that in Valleix's twenty-four cases 
twenty-two were fatal. M. Auvity estimates the mortality of such cases 
at nine in ten, and M. Godinat at two in three. 

Treatment. — As one of the most common causes of thrush is the use 
of indigestible or improper food, the physician should ascertain the nature 
of the infant's diet, and if it is faulty should direct a better. In many 
cases the infent is bottle-fed. It should be given only the mother's milk 
if practicable, or that of a healthy wet-nurse. This change of alimenta- 
tion often removes the sole cause of thrush in the young infant, so that it 
rapidly recovers. 

If artificial feeding is necessary, such diet should be advised as is directed 
in our remarks on the treatment of the diarrhoeal maladies. There is often 
in thrush an excess of acidity in the digestive tube, and an alkali is re- 
quired. Trousseau recommends the addition of saccharate of lime to the 
milk. Children with this disease should also be taken from filthy and 
damp apartments, to those in which the air is pure and dry, and their 
mouths and persons should be kept clean. 

The remedy in common use in the treatment of thrush, and which is 
usually eflectual, is borax. This, if applied sufficiently often to the affected 
membrane, not only destroys the parasitic growth, but prevents its repro- 
duction. It is commonly employed with honey, or in a powder with sugar 
or dissolved in water. The officinal mel boracis, consisting of one part of 
borax to eight of honey, is so much used in families that it may be con- 
sidered almost a domestic remedy. There is, however, an objection to 
using any application for the removal of thrush which contains either sugar 
or honey, since either substance remaining in the mouth would rather pro- 
mote the growth of the parasite. Still, it is desirable to employ a wash 
of such consistence that it will remain a longer time in contact with the 
buccal surface than will a simple solution in water. I know no better vehicle 
for the borax than glycerin, which has the advantage of consistence, does 
not undergo any chemical change, and has no unpleasant flavor. The borax 



GANGRENE OF THE MOUTH. 563 

may be used dissolved iu glycerin, with or without some flavoring ingre- 
dient : 

R. Sodas borat., gj. 
Glycerinse, ^ij. 
Aquse, gvj. Misce. 

Borax should be used four or five times daily, and continued for a time 
after the disease has disappeared from sight, since the roots of the plant 
must be destroyed or the branches are rapidly reproduced. It should be 
applied by a camel-hair pencil, or with a soft cloth upon the finger or a 
stick. It should be so freely used, in extensive and severe forms of the 
disease, that the infant will swallow some, as the entire oesophagus is apt to 
be afiected in such cases. In the intervals between the applications of borax, 
if the buccal surface is hot, dry, and tender, so as to increase the fretful- 
ness of the infant, it is well to use mucilaginous washes, as the mucilage 
of acacia or mallows. If the disease continue notwithstanding the use of 
these measures, the mouth should be occasionally washed with a weak solu- 
tion of nitrate of silver or sulphate of zinc : 

R. Zinci sulph., gr. ii-iv. 
Aq. rosse, §ij. Misce. 

In many cases, however, the treatment of thrush is of less importance 
than that of the disease which the thrush complicates. The remedial 
measures which I have mentioned then become subordinate to those em- 
ployed for the graver disease. When this disease is relieved and the gen- 
eral health improves, thrush is more easily and permanently cured than 
during the state of feebleness and ill-health. 



CHAPTER III. 

GANGRENE OF THE MOUTH. 

The diseases of the mouth which we have been considering are attended 
by little danger, but the one which we are next to consider, is among the 
most fatal of early life. It is gangrene of a portion of the cheek or gums, 
or of both. It is described by writers under various names, as caucrum 
oris, noma, necrosis infantilis, aqueous cancer of infimts. 

Anatomical Characters. — Gangrene of the mouth is sometimes pre- 
ceded by ulceration of the mucous membrane, at the point where it is about 
to commence, but in other cases this membrane is entire. The tissues at 



564 GANGRENE OF THE MOUTH. 

the point of attack, which is most frequently the inside of the cheek, be- 
come inflamed, thickened, and indurated. The induration extends, and 
soon the purple hue of gangrene appears and increases. The next stage in 
the progress of gangrene is sloughing of the portion the vitality of which 
is lost. 

The slough does not present the appearance of uniform decay. While 
the color is generally dark, there are in the mass fibres of connective tissue 
or even bloodvessels, which remain unchanged or are but partially decom- 
posed. After separation or sloughing of the part where the vitality is first 
lost, the surface of the excavation, if the disease is not checked, has a dark, 
jagged, and unhealthy appearance. Commencing with the mucous mem- 
brane and the tissue immediately underlying it, the disease extends on the 
one side towards the skin, and on the other towards the deeper-seated 
structures of the jaw. According to Billard, the swelling which precedes 
and surrounds the gangrene is in great part oedematous. 

This disease is occasionally primary, but in a large proportion of cases 
it is secondary. Occurring secondarily, its symptoms are often masked by 
those of the antecedent and coexisting affection. Under such circum- 
stances attention is sometimes first directed to the mouth, by the loosening 
of one or more of the teeth, or the appearance on the skin of a livid cir- 
cular spot, which indicates the approach of the disease to the cutaneous 
surface. The mucous membrane presents a dark-red appearance to the 
distance of a few lines beyond the point of gangrene. It covers tissues 
which are inflamed and indurated and about to become gangrenous. 

The tongue is usually more or less swollen, unless the disease is mild; 
an offensive odor arises from the gangrene, due to the evolution of sul- 
phuretted hydrogen and other gases. There is great difference in the ex- 
tent of the destruction, and the gravity of the disease, in different cases. 
It may sometimes be arrested by proper applications and a favorable 
change in the general health of the child at an early period, when there is 
little loss of substance. In other cases it extends till it perforates the 
cheek, or even destroys a considerable part of the side of the faqe, and, ex- 
tending inwards, attacks the periosteum of the maxillary bone, destroying 
the gum and teeth, and denuding the alveoli. Recovery, if it take place 
at all under such circumstances, is with the loss of a portion of the bone, 
and with deformity. 

The duct of Steno is sometimes included in the gangrenous portion, but 
it commonly resists the destructive process, and remains pervious. 

Age. — The age at which gangrene of the mouth occurs is usually be- 
tween two and six years. In twenty-nine cases collated by Rilliet and 
Barthez, twenty-one were between the ages of two and six years, and the 
remaining eight were from six to twelve years old. Of the cases which 
have fallen under my observation, all were between the ages of two and 
six years. It -is seen that the period of greatest frequency of gangrene of 



CAUSES SYMPTOMS. 565 

the mouth is different from that at which the ordinary forms of stomatitis 
occur. 

Gangrene of the mouth may, however, occur under the age of one year. 
Billard reported three cases under the age of one month, but in two of 
these the disease does not appear to have been sufficiently marked to ren- 
der it certain that they were genuine cases. 

Causes. — Gangrene of the mouth usually occurs in those whose systems 
are reduced or cachectic. It is, therefore, more frequent among the poor 
than those in comfortable circumstances; in the city than in the country. 
It is more frequently observed in asylums for children than in private 
practice. Half the cases which I have seen have been in these institu- 
tions. If the constitution is naturally good, it can only occur in those long 
deprived of pure air and wholesome nutriment, or those enfeebled by dis- 
ease. 

Among the diseases which have been known to terminate in or be fol- 
lowed by gangrene of the mouth, are the pulmonary and intestinal inflam- 
mations, hooping-cough, and the fevers, both eruptive and the non-eruptive. 
Rilliet and Barthez have published a table of ninety-eight cases in which 
gangrene resulted from other diseases. In forty-one of these the antece- 
dent disease was measles, in five scarlet fever, six hooping-cough, nine 
intermittent fever, nine typhoid fever, seven mercurial salivation, and five 
enteritis. It is seen that the essential fevers were the most frequent cause 
of the gangrene. Of forty-six cases collected by MM. Bouley and Cail- 
lault, the antecedent disease was measles in all but five. In this city, also, 
a larger number occur from measles than from any other disease. 

One reason why so many cases of j^angrene occur as a sequel of measles 
is probably because this disease is accompanied by stomatitis. Simple or 
ulcerous stomatitis often precedes gangrene. 

Diseases sometimes terminate in gangrene of the mouth chiefly in con- 
sequence of injudicious treatment, which has lowered the vitality of the 
system. Rilliet and Barthez mention the case of a child four years old, in 
whom gangrene commenced at the twenty-ninth day of primit-ye pneu- 
monia. This child had been reduced by the application of twelve leeches, 
three scarifications, a large blister, and by the use of absolute diet. 

The misuse of mercury was once a much more frequent cause of gan- 
grene than at present, at least in this country, since this agent was formerly 
much more employed than now. In fact most of the affections of infancy 
and childhood in which mercurials were formerly employed are now treated 
without it. 

Symptoms. — Gangrene of the mouth so often occurs in connection with 
other disease, that its symptoms are in a large proportion of cases blended 
with those which arise from a distinct pathological state. 

There is usually prostration more and more pronounced as the gangrene 
extends. The features are ordinarily pallid, but occasionally their normal 



566 



GANGKENE OF THE MOUTH. 



color is preserved for a time; the expression of the face is melancholy, 
but composed. Sometimes the child is fretful, if disturbed ; at other 
times it will quietly consent to an examination. The suffering is not 
proportionate to the gravity of the disease. There is less pain often than 
in some of the forms of stomatitis which are unattended with danger. 

As the disease advances, the body and limbs gradually waste, the eyes 
are hollow, or, if the gangrene is near the orbit, the eyelids become 
cedematous, the lips are infiltrated, and both the lips and nostrils are 
often incrusted. If the cheek is pei'forated, alimentation is rendered 
more difficult, and the appearance of the child is melancholy in the ex- 
treme. 

Fig. 




The tongue is usually moist ; it is occasionally swollen. The saliva 
flows from the mouth, either pure or mixed with offensive sanguinolent 
matter. Unless the disease is slight, there is the peculiar gangrenous 
odor. The appetite is sometimes poor, at other times it is preserved 
through the whole sickness. There is no vomiting or looseness of the 
bowels, unless from a complication. The thirst is usually great, and the 
pulse is accelerated and feeble, except in mild cases. 

The skin in the commencement of gangrene is hot. When the vital 
force is much reduced, and especially as the disease approaches a fatal 
termination, the face and limbs become cool, and the surface generally 
presents a waxen or ashy appearance. There is no derangement of the 
respiratory system. Those cases which are attended by a cough or acceler- 



DIAGNOSIS — PROGNOSIS. 567 

ated respiration are really cases of bronchitis or pneumonitis, coexisting 
with the gangrene. 

Diagnosis. — Gangrene of the mouth is easily diagnosticated. In 
those cases in which ulceration precedes the gangrene, it might be mis- 
taken in its first stages for that form of ulcerous stomatitis in which the 
ulcers assume an unhealthy appearance. The following are the distin- 
guishing features of the two affections : Around the ulcer where gangrene 
is about to commence the tissues are greatly thickened and indurated, or 
cedematous, while ulcerous stomatitis begins with a submucous deposit of 
fibrin, and is attended by little thickening of the surrounding parts, and 
little or no induration or oedema. In ulcerous stomatitis the skin over the 
seat of the disease presents its normal appearance, whereas in gangrene it 
presents a distended and shining appearance. The destructive process in 
ulcerous stomatitis is also more limited than in gangrene. Deep ulcer- 
ations do not occur, or are rare. Ulcerous stomatitis is more readily 
healed, and it leaves no eschar, contraction, or deformity. 

The differential diagnosis of gangrene of the mouth from those cases 
of follicular stomatitis in which the ulcers occupying the seat of the fol- 
licles assume a gangrenous appearance, must be made by a consideration 
of the same facts or particulars which serve to distinguish it from ulcerous 
stomatitis. 

Malignant pustule, of rare occurrence in the child, resembles this dis- 
ease in some of its features. But the pustule always begins on the skin, 
while gangrene is a disease of the mucous surface primarily. In gan- 
grene, therefore, the chief destruction is of the mucous membrane and of 
the submucous tissue, while in malignant pustule the chief destruction is 
of the skin and the subcutaneous tissue. 

Prognosis. — This depends, not only on the extent of the gangrene, 
but the nature of the disease, if there be one, which gave rise to it, and 
the degree of cachexia. If it occurs in connection with or as a sequel of 
one of the least debilitating diseases, and there is considerable vigor of 
system, it may often be arrested when it has destroyed only the mucous 
and subcutaneous tissues, so that no deformity results. The friends may 
congratulate themselves if the case terminate so favorably. In the graver 
cases, when the gangrene extends till it destroys the periosteum of the 
maxillary bone on the affected side, and perhaps perforates the cheek, it 
the child recovers it is with the permanent loss of teeth, tedious separation 
of the necrosed bone, and a cicatrix, which is apt to interfere with the 
free use of the jaw. Death is, however, the more common termination of 
severe cases. Occasionally the gangrene destroys the continuity of a 
bloodvessel, causing abundant ha;morrhage, and accelerating the fatal 
result. In most cases, however, there is little or no haemorrhage, in con- 
sequence of coagulation in the vessels. 

Another serious complication occasionally arises, namely, gangrene of 



568 GANGRENE OF THE MOUTH. 

other 23arts, as of the external genital organs. The English editor of 
Bouchut's treatise on diseases of children, relates the following interesting 
case, from the Transactions of the Edin. Medico- Chir. Society : 

An infant eight months old became affected with gangrene of the face, 
head, and hands, " The right ear and the entire hairy scalp were of an in- 
tensely black color, and on both cheeks patches existed about the size of 
a half-crown piece. The right thumb and the backs of both hands were 
similarly affected. The child was noted to have been restless and feverish 
on May 22d, and on the 23d a slightly darkened ring was found to have 
formed round the thumb, about the middle of the first phalanx; in a few 
hours the whole thumb was gangrenous, and the dorsum of the hand became 
involved. On the ear the gangrene commenced with the appearance of a 
fleabite, and subsequently extended rapidly to the scalp, assuming a re- 
markably regular form, and giving to the child the appearance of wearing 
a black skullcap. The pulse was observed to be very feeble. . , . Death 
took place in twelve hours from the first appearance of gangrene on the 
thumb, the child being sensible and continuing to suck well, up to a few 
minutes before death." 

Rilliet and Barthez state that pneumonitis is apt to arise in the course 
of gangrene of the mouth. Such a complication evidently diminishes 
materially the chance of recovery. 

Whether the result be favorable or unfavorable, it is evident, from the 
nature of the disease, that the duration is very different in different cases. 
The physician's attendance may be required for a week or two or for sev- 
eral weeks. 

Treatment. — As gangrene of the mouth is eminently a disease of de- 
bility, all anti-hygienic influences should be removed, and the most nour- 
ishing diet, together with tonics, be recommended. The ferruginous 
preparations or the bitter vegetables are required. 

As soon as the physician is called, he should endeavor to arrest the 
gangrene, accelerate the detachment of the slough, and produce a healthy 
and granulating state of the surrounding tissues. This is best effected by 
applying a highly stimulating or even escharotic agent to the inflamed 
surface underneath and around the gangrene. For this purpose a great 
variety of substances have been used by different physicians; such as acetic, 
sulphuric, nitric, and hydrochloric acids, nitrate of silver, the acid nitrate 
of mercury, chloride of antimony, and even the actual cautery. 

M. Taupin recommends, after removing a considerable part of the gan- 
grenous substance with scissors or some instrument, the application of 
strong muriatic acid, and, when the slough is detached, of dry chloride of 
lime. 

Rilliet and Barthez advised the use twice daily of muriatic acid or the 
acid nitrate of mercury, applied by a brush upon and around the slough, 
followed immediately by the application of dry chloride of lime, when the 



TREATMENT. 569 

moutb is to be thoroughly washed with water from a syringe. They di- 
rect in the interval frequent ablution with water. After the slough has 
separated, the escharotic is to be discontinued, and the chloride of lime 
used alone. If gangrene extends to the skin, a crucial incision is to be 
made and the escharotic applied, after which powdered cinchona is intro- 
duced and retained by a plaster. This treatment is to be continued till 
the gangrene is arrested and the decayed portion removed. Barrier, 
Valleix, and most French writers, recommend essentially the same treat- 
ment, namely, the application of undiluted escharotic agents. 

A safer, less painful, and, in my opinion, preferable, treatment, is that 
employed by many British and American physicians, namely, the use of 
escharotic agents diluted, or, if applied in their full strength, such as are 
least active and penetrating. Some employ from the first topical treat- 
ment which is astringent and stimulating rather than escharotic, and they 
report satisfactory results. 

Dr. Gerhard believes " the best local applications are the nitrate of sil- 
ver, if the slough be small in extent ; if much larger, the best escharotic 
is the muriated tincture of iron, applied in the undiluted state. After the 
progress of the disease is arrested, the ulcer will improve rapidly under 
an astringent stimulant, such as the tincture of myrrh, or the aromatic 
wine of the French Pharmacopoeia." 

The local treatment recommended by Evanson and Maunsell I believe 
to be preferable to that advised by any of the writers from whom I have 
quoted. I have seen it so successful, that I should employ it in all ordi- 
nary cases from the first visit. A knowledge of this treatment will be 
best imparted by quoting from the authors (^.Diseases of Children, 2d 
Amer. edit., page 188) : " The lotion which we have found by far the 
most successful is a solution of sulphate of copper, as employed by Coates 
in the Children's Asylum. His formula is as follows : 

"R. Cupri sulph., ^ij. 

Pulv. cinchonas, gss. 
Aquse, giv. M. 

" This is to be applied twice a day very carefully to the full extent of 
the ulcerations and excoriations. The addition of the cinchonse is only 
useful by retaining the sulphate of copper longer in contact with the 
edges of the gums. A solution of the sulphate of zinc, 5j to an ounce of 
water, by itself or combined with tincture of myrrh. Dr. Coates found to 
be also useful in some cases." 

A moment's reflection will show us that the above treatment is far 
preferable, provided it is equally effectual in arresting the gangrene, to 
the treatment by the strong escharotics which some of our best prac- 
titioners employ. 

Take, for example, the use of pure nitric or muriatic acid, which phy- 



570 DENTITION. 

sicians of experience recommend. This agent causes such pain that it 
occasions restlessness of the child, and such stout resistance that the use 
of chloroform has been recommended to facilitate its application. The 
pain occurring from it and from the inflammation which it excites doubt- 
less reduces the strength which it is very necessary to preserve. If the 
a<;id comes iu contact with the teeth, as it generally will, it injures them 
irreparably, and it sometimes attacks the jaw-bone. Dr. West, who ad- 
vocates the use of the acid (Diseases of Infancy and Childhood, 4th Amer. 
edit., page 467), says : " In one of the cases that I saw recover, the arrest 
of the disease appeared to be entirely owing to this agent, though the 
alveolar processes of the left side of the lower jaw, from the first molar 
tooth backwards, died and exfoliated, apparently from having been de- 
stroyed by the acid." No such result follows the use of the solution of 
sulphate of copper, and of its efficacy I can speak confidently. In one of 
those severe cases in which the disease resulted from scarlet fever, and in 
which there was so much debility that an unfavorable prognosis was made, 
I succeeded in arresting the disease by the use of Dr. Coates's prescription. 
The child recovered with the loss of two teeth and the corresponding por- 
tion of the maxillary bone. From the good eflTects which I have observed 
from iodoform, as an application for gangrenous vulvitis following measles, 
it has occurred to me that it may also be useful in gangrene of the mouth. 

The application should be made twice a day till the gangrene is arrested 
and healthy granulations appear. 

The gases arising from the gangrenous mass are not only highly offensive 
to others, but they are doubtless injurious to the patient, who is constantly 
inhaling them. To remove the fetor, chlorine or carbolic acid, properly 
diluted, should be occasionally used between the applications of the sul- 
phate of copper. Labarraque's solution, one part to eight or ten parts of 
water, is an eligible form for its use. When the gangrene is removed, and 
the granulations present a healthy appearance, all danger is usually past 
and convalescence is fully established. Then no energetic topical treat- 
ment is required. A mild stimulating lotion, like the tincture of myrrh, 
as recommended by Dr. Gerhard, suffices, with the aid of tonics and nu- 
tritious diet. 



CHAPTER IV. 

DENTITION. 

The part which dentition bears in the causation of disease is not fully 
ascertained. We know that the opinion formerly entertained in the pro- 
fession, and now prevalent in the community, that a large proportion of 
the aflfections of infancy arise directly or indirectly from it, is erroneous. 



DEFINITION. 571 

Still, many of the best authorities in infantile pathology concur in the 
belief that difficult and painful evolution of the teeth frequently causes 
derangement in the functions of organs, even those remote from the mouth, 
and sometimes produces in them a real pathological state. They, therefore, 
frequently speak of dentition as a cause of disease. On the other hand, 
there are physicians, equally good observers, and the number is increasing, 
who almost wholly ignore the pathological results of dentition. They 
say that, as it is strictly a physiological process, it should, like other such 
processes, be excluded from the domain of pathology. Experience, they 
assert, corroborates this opinion, and therefore dentition should seldom, if 
ever, be interfered with by the lancet or other means. 

A moment's reflection will show how important it is to understand the 
exact relation of dentition to infantile diseases. Every physician is called 
now and then to cases of serious disease, inflammatory and others, which 
have been allowed to run on without treatment, in the belief that the symp- 
toms were the result of dentition. I have known acute meningitis, pneu- 
monitis, and entero-colitis, even with medical attendance, to be overlooked 
during the very time when appropriate treatment was most urgently de- 
manded. Many lives are lost in this manner, especially from neglected 
entero-colitis, the friends and even physicians believing the diarrhoea to be 
symptomatic of dentition, a relief to it, and therefore not to be treated. 
Such mistakes are traceable to the erroneous doctrine, once inculcated in 
the schools, and now believed in by the more ignorant of the laity, that 
dentition is directly or indirectly a common cause of infantile diseases and 



May there not be an error in the opposite direction ? May not some 
diseases be rendered milder, and their favorable termination more certain 
or probable, by measures calculated to relieve the turgescence of the gums ? 
If so, those who totally disregard the state of the gums are not less in error 
than those who use the gum-lancet when it is not required. 

I shall endeavor to point out what is really ascertained in regard to the 
relation of dentition to disease. 

First dentition commences at the age of about six months and termi- 
nates at the age of two and a half years. The corresponding teeth of the 
two sides pierce the gum at about the same time. The two inferior central 
incisors first appear at about the age of six or seven months, followed, in 
the order in which they are mentioned, by the upper central incisors, upper 
lateral incisors, lower lateral incisors, the four anterior molars, the four 
canines, and, lastly, the four posterior molars. 

The incisors usually appear in rapid succession, so that all are in sight 
by the age of one year. From the age of one year to sixteen months the 
anterior molars penetrate the gum, from the age of sixteen to twenty-four 
months the canines, and from twenty-four to thirty months the posterior 
molars. 



572 DENTITION. 

This order is not always preserved. Sometimes the upper central in- 
cisors appear before the lower, and sometimes the lower lateral before the 
upper lateral. In rare cases there have been teeth at birth. I have seen 
but one or two infants with such premature dentition. Retarded dentition 
is much more common. Tltose who have rickets, or are feeble either con- 
stitutionally or by disease, often have no teeth till considerably after the 
usual period. In such the first incisors may not appear till the age of 
twelve months, or even later. 

Pathological Results of Dentition. — The evolution of the teeth is 
commonly attended by more or less turgescence around the dental bulbs. 
This is greater with some of the teeth than with others. Thus, the superior 
incisors cause more swelling than do their congeners of the inferior jaw. 
The turgescence, although it may be attended by more or less congestion, 
is so common that it is hardly proper to call it a disease. Turgescence, 
with redness and more or less tenderness of the swollen gum, may be con- 
sidered the simplest pathological state. 

In other cases there is an unusual amount of swelling around the dental 
follicles ; the afflux of blood to them is greatly augmented ; they ai'e the 
seat of such a degree of tenderness and pain that the infant is fretful. It 
carries the finger often to the mouth, indicating the seat of its suflfering. 
The surface over the follicles presents greater redness than in ordinary 
dentition, and the salivary secretion is considerably increased. There is 
now actual gingivitis. 

Sometimes the inflammation affects a greater extent of the buccal sur- 
face than that lying directly over the follicles, so that most writers speak 
of stomatitis as one of the results of dentition. In a few cases I have 
known such a degree of inflammation over the advancing tooth, that a 
small abscess formed, producing much joain and restlessness, till it was 
opened by the lancet. 

The pathological results of dentition which I have mentioned are unim- 
portant in comparison with others not yet alluded to. They do not en- 
danger the life of the child. They are easily detected. They result di- 
rectly from the rapid growth and augmented sensibility of the dental 
follicles. 

There are other accidents of dentition occurring in distant parts of the 
system in consequence of that mysterious relation and interdependence of 
organs which exist through the system of nerves. 

These accidents are more serious, and their relation to dentition is ob- 
viously less readily ascertained than are those located in the mouth. The 
most common of them occur in the stomach and intestines. 

Some children, previously to the eruption of the teeth, are affected with 
diarrhoea, occasionally accompanied by irritability of stomach. Certain 
writers have supposed that gastro-intestinal inflammation is present in 
these cases ; others that there is simply a hypersecretion, an increased ae- 



PATHOLOGICAL RESULTS OP DENTITION. 573 

tivity of the intestinal follicular apparatus, that it is, in other words, one 
of the forms of non-inflammatory diarrhoea. Barrier believes that the 
diarrhoea of dentition depends usually on what he calls a " subinflarama- 
tory turgescence limited to the gastro-intestinal follicular apparatus." He 
believes that, in occasional cases, it is due to defective or altered innerva- 
tion. It would then be analogous or similar to that form of diarrhoea 
which occurs in the adult from the emotions. Bouchut calls the diarrhoea 
of dentition nervous diarrhoea. It is certain, however, that in most cases 
of diarrhoea which are attributed to dentition there are other causes, such 
as unsuitable food, or residence in an insalubrious locality. It is certain, 
as regards city infants, that the chief causes of diarrhoea during the period 
of dentition are strictly anti-hygienic, dentition being quite subordinate as 
a cause, and probably often not operating at all as su^ch. But when, as 
sometimes happens, at each period of dental evolution, the infant is af- 
fected wath diarrhoea, the influence of teething is apparent. Such cases 
enable us to see that teething may really sustain a causative relation to 
certain diseases not located in the buccal cavity. 

Among the most common pathological results of difiicult dentition, are 
certain affections referable to the cerebro-spinal system. Eclampsia is one 
of the admitted results. Barrier attributes convulsions in the teething in- 
fant to excitement of the nervous system arising from the pain which is 
felt in the gums, and to a determination of blood to the dental apparatus, 
in which afflux the whole vascular system of the head participates. 

In most cases of convulsions occurring during the period of dental 
evolution, a careful examination discloses other causes in addition to the 
state of the gums. Difiicult dentition must then be considered, not so fre- 
quently a direct as a co-operating or predisposing cause, producing a sensi- 
tive state of the nervous system, or possibly an afSux of blood to the head, 
of which Barrier speaks, and which, by an additional stimulus, perhaps 
trivial in itself, ends in convulsions. In exceptional instances eclampsia 
occurs mainly from dentition, or, if there are other causes, they are quite 
subordinate. This may happen when several teeth penetrate the gum at 
or about the same time. Infants who are burnt or scalded are very liable 
to clonic convulsions. This is, in fact, the chief danger as regards life 
from such accidents. So, the swollen and tender gum, if several teeth are 
about emerging, may affect the cerebro-spinal system like the burn or 
scald, and produce the same nervous phenomena. Thus, in a case already 
alluded to in the chapter on convulsions, five incisors pierced the gum within 
about two weeks, and ip this period there were two attacks of eclampsia 
with an interval of a few days. The attacks were not severe, and the 
most careful examination could discover no other cause than the simul- 
taneous development of so many dental follicles. Previousl}'-, and since, 
the infant has been well. 

Dentition sometimes, though rarely, occasions also tonic convulsions. 



574 DENTITION. 

The following case occurred in the practice of Dr. A. S. Church, of this 
city, the history of which he has kindly communicated, as follows : 

" H., seven months old, was first visited April 3d, 1863. The patient 
had been fretful for several days, but about daylight on the morning of 
my first visit it commenced crying, and had not ceased for a moment at 
the time of my visit, 9 a.m. The bowels were somewhat constipated and 
tympanitic ; abdominal muscles very tense. The pain was supposed to be 
in the abdomen, and a brisk cathartic, to be followed by an anodyne, was 
ordered. Some relief followed, but, on the ensuing and for several con- 
secutive mornings, the pain returned, each day lasting longer, until the 
child only ceased crying while under the influence of a full anodyne. 
The gum over the upper incisors was considerably swollen, hot, and dry, 
but the parents would not consent to have it scarified. For the first 
week there was no fever, no vomiting, and not the least indication that 
the nervous system was suffering. About the 10th the thumbs were noticed 
to be flexed during the attack of pain, and about the 15th the flexors of 
the toes were contracted and the hands were turned backwards and out- 
wards, but only while the child was awake. About the 20th there was 
constant contraction of the flexors of both extremities, with opisthotonos, 
and constant rolling of the head, loss of appetite, progressive emaciation, 
coated tongue, and highly inflamed gums. Consent was, finally, obtained 
to relieve the inflamed gum, and free incisions were made, and the follow- 
ing night the child slept comfortably for three hours without opiates. In 
three days the gums were freely cut again, and the teeth soon made their 
appearance. All symptoms of disease had now ceased, the child became 
playful, and on the 30th the patient was discharged." 

The opinion has been prevalent in the profession, that painful and diffi- 
cult dentition is one of the chief causes of infantile paralysis, but it is now 
commonly admitted that it is only a subordinate or remote cause, if indeed 
it is proper to consider it as a cause at all. (See Art. Paralysis.) 

Some writers express the opinion that acute meningitis occasionally 
results from teething. The facts, however, that are relied upon to prove 
this are uncertain. The occurrence of meningitis during dentition is 
probably in most instances a coincidence. 

Teething less frequently disturbs the respiratory system than either the 
digestive or cerebro-spinal. A cough occurs in some infants at each period 
of dental evolution. It is attended by little expectoration, but appears to 
be associated with, in at least certain cases, an inflammatory turgescence 
of the bronchial mucous membrane. 

Acceleration of pulse is often observed at the time of greatest swelling 
and tenderness of the gum. It subsides with the protrusion of the tooth. 
The febrile movement of dentition is irregular, sometimes presenting a re- 
mittent form, like remittent fever or the fever premonitory of meningitis. 
Eczema and certain other cutaneous diseases are common during dentition, 
but their dependence on it as a cause has not been demonstrated. 

Diagnosis. — The accidents of dentition which are located in the mouth 



TREATMENT. 575 

are easily diagnosticated, except the odontalgia which writers describe, and 
which is not necessarily attended by any perceptible anatomical alteration 
of the gums. Those accidents which pertain to remote and concealed or- 
gans are usually detected with ease, though it is often difficult to deter- 
mine with certaiiaty their relation to dentition. 

When similar symptoms arise at each epoch of teething, and subside 
with the subsidence of the gingival turgescence, teething must be regarded 
as the cause. Or, if the disease is such as is known to be produced occa- 
sionally by difficult teething, and if, after a careful examination, we can 
discover no other cause, while the gums are swollen, especially over two or 
'more advancing teeth, it is proper to refer the malady to dentition. 

It is evident that we must often be in doubt whether the disease which 
we are treating is due at all to the state of the gums, or, if so, whether 
directly or indirectly, or to what extent ; but, as a rule, if any other cause 
is apparent, we may properly regard the influence of dentition as quite 
subordinate. 

Treatment. — It is obvious that remedial measures in cases of difficult 
dentition must be twofold, namely, those directed to the state of the gums, 
and those designed to relieve the derangements or diseases to which den- 
tition has given rise. If there is diarrhoea, this should be controlled by 
proper remedies, so as to reduce the number of evacuations to two or three 
daily. It is well to state to the friends of the child, who believe that diar- 
rhoea is salutary during the period of teething, that this number is quite 
sufficient, aild that more frequent evacuations will endanger the safety of 
the child. 

The nervous affections, as convulsions, require such soothing and deriv- 
ative measures as are recommended in our remarks on diseases of the 
nervous system. The. bromide of potassium I have found especially useful 
and safe in cases of fretfulness and nervous excitement due to dentition. 
The rational employment of therapeutic measures requires strict attention 
to be given to the causes of disease. Therefore, the physician called to 
treat an ailment, believed to be due to dentition, should not fail to examine 
the state of the gums, and adopt such measures as will mitigate the inten- 
sity of the cause — in other words, diminish the tenderness if not the swell- 
ing of the gum. Demulcent and soothing lotions are sometimes useful. 
The infant should be allowed to hold in the mouth an india-rubber or 
ivory ring, which by pressure on the gum gives considerable relief 

Mothers will often attempt to "rub through a tooth," as they terzn it, by 
means of a ring or thimble. This should be discouraged. So great fric- 
tion cannot fail to have an injui-ious effect, by increasing the swelling 
and inflammation, unless the tooth has already reached the mucous mem- 
brane. 

We come now to a subject which has engaged the attention of many of 
the ablest and most experienced physicians, and in reference to which there 



576 DENTITION. 

is still a difference of opinion among the highest authorities in medicine. I 
refer to scarification of the gums. 

The gum-lancet is now much less frequently employed than formerly. 
It is used more by the ignorant practitioner, who is deficient in the ability 
to diagnosticate obscure diseases, than by one of intelligence, Avho can dis- 
cern more clearly the true pathological state. Its use is more frequent in 
some countries, as England, under the teaching of great names, than in 
others, as France, where the highest authorities, as Rilliet and Barthez, 
discountenance it. 

It is well to bear in mind, as aiding in the elucidation of this subject, the 
remark made by Trousseau, that the tooth is not released by lancing the 
gum over the advancing crown. The gum is not rendered tense by pressure 
of the tooth, as many seem to think, for, if so, the incision would not re- 
main linear, and the edges of the wound would not unite, as they ordi- 
narily do by first intention within a day or two. This speedy healing of 
the incision, unless the tooth is on the point of protruding, is an important 
fact, for it shows that the effect of the scarification can only last one or two 
days. The early repair of the dental follicle is propably conservative so 
far as the development of the tooth is concerned. It may help us to under- 
stand how active, how powerful, the process of absorption is, if we reflect 
that the roots of the deciduous teeth are more or less absorbed by the ad- 
vancing second set, without much pain or suffering from the pressure. If 
the calcareous particles of the teeth are so readily absorbed, what is the 
foundation for the belief that the fleshy substance of the gum is absorbed 
with such difiiculty? Too much importance has evidently been attached 
to the supposed tension and resistance of the gum in the process of dentition. 

Follicles in the period of development are especially liable to inflamma- 
tion. We see this in the follicular stomatitis and enteritis, so common 
when the buccal and intestinal follicles are in the state of most rapid 
growth. Does not this law in reference to the follicles hold true of those 
by which the teeth are formed, so that the period of their enlargement 
and greatest activity, which corresponds with the growth and protrusion 
of the teeth, is also the period when they are most liable to congestion and 
inflammation ? This fact affords a better explanation of the frequency of 
the so-called laborious or difficult dentition than that it is due to the re- 
sistance which dental evolution encounters from the gums. 

If there are no symptoms except such as occur directly from the swell- 
ing and congestion of the gum, the lancet should seldom be used. The 
pathological state of the gum which would, without doubt, require its use, 
is an abscess over the tooth. As to symptoms which are general or refer- 
able to other organs, as fever and diarrhoea, the lancet should not be used 
if the symptoms can be controlled by other safe measures. All co-opera- 
ting causes should first be removed, when in a large proportion of cases 
the patient will experience such relief that scarification can be deferred. 



SECOND DENTITION. 577 

If the state of the iufant is one of immediate danger, as in convulsions, 
and it is not quickly relieved by the ordinary remedies, scai'ification of the 
gums may not only be proper but urgently required. For in such cases 
all measures, provided they are safe and simple, which can possibly give 
relief should be employed without delay. But I can recall to mind only 
two accidents of dentition which would be likely to be benefited by scarifi- 
cation, namely, suppurative inflammation in the dental follicle and con- 
vulsions. But since the bromide of potassium has come into use as a ner- 
vous sedative, and as an efiicient remedy for clonic convulsions, scarifica- 
tion of the gums is much less frequently required, for even severe eclampsia 
commonly yields to this medicine, if the condition of the bowels is attended 
to. Cutting the gums is now abandoned as a means of relief in infantile 
paralysis, for this malady is known to be due to other causes than den- 
tition. 

Second Dentition. 

The fact is well established, though often overlooked in practice, that 
second dentition occasionally deranges the functions of organs, and gives 
rise to pathological symptoms. Rilliet and Barthez mention particularly 
neuralgic pains, rebellious cough, and diarrhoea, as efiects which they have 
observed. Rilliet relates the case of a girl, eleven years old, who had a 
very obstinate and protracted cough, the paroxysms lasting often half an 
hour to one hour. This cough immediately and permanently disappeared 
when the molars pierced the gums. 

Dr. James Jackson, in his Letters to a Young Physician, says: "I have 
seen persons between twenty and thirty years of age much affected by a 
wisdom tooth not yet protruded, and distinctly relieved by cutting the gum. 
But I think the most common period of sufifering from the second denti- 
tion is from the tenth to the thirteenth year. The most characteristic 
affections are wasting of flesh and nervous diseases. The boy loses his 
comeliness, and his complexion is less clear, while emaciation takes place 
in every part, though mostly, perhaps, in the face. The nervous symp- 
toms are various, but the most common are a change in the temper and 
a loss of spirits. With these there is some loss of strength. The patient 
is unwilling to engage in play, and soon becomes tired when he does do it. 
Among the distinct symptoms which are not uncommon, I may mention 
pain in the head and in the eyes. The headache is not commonly severe, 
but it is such as inclines the patient to keep still. The eyes are not only 
painful, but are often affected with the morbid sensibility to which these 
organs are subject. I have known boys truly anxious to pursue their 
studies obliged to give them up on this account; and these, not having the 
disposition to play, will of choice pass the day with their mothers, and in- 
crease their troubles by the want of air and exercise. Nervous affections 
of a more severe character are sometimes manifested." 

37 



578 SIMPLE PHARYNGITIS. 

Whether the symptoms which have been attributed to second dentition 
have always been due to this cause, is questionable. Practically, how- 
ever, it matters little, whether we recognize dentition as the cause, or as- 
sign something else. Hygienic and medicinal measures to improve the 
general health will usually suffice to relieve the patient. Elsewhei'e I have 
related the case of a boy, of nervous temperament, about seven years old, 
who recovered immediately from a cough which had lasted for several 
weeks, by taking a mixture of iron and nitric acid. Many do well without 
medicine, simply by hygienic measures. Dr. Jackson says, " The remedies 
which I have found most useful are as follows : First, a relief from study 
or from regular tasks, yet using books so far as they afford agreeable 
occupation or amusement. Second, exercise in the open air, preferring 
the mode most agreeable to the patient, and in more grave cases the 
removal from town to country." 



CHAPTER V. 

SIMPLE PHAllYNGITIS, PERI-PHAKYNGEAL ABSCESS. 
(ESOPEAGITIS. 

Children of all ages are liable to inflammation of the pharynx. In 
its mildest form it often, doubtless, escapes detection in the young infant. 
In older patients it is revealed by pain in swallowing solid food, and more 
or less tumefaction below the ears apparent to the sight. It is said to be 
less frequent in infancy than in childhood. In the adult, and in children 
over the age of four or five years, inflammation of the pharyngeal surface 
is often confined to the portion of membrane which covers or immediately 
surrounds the tonsils. It occurs in connection with inflammation of these 
glands. But in infancy and early childhood this limitation is compara- 
tively rare. Inflammation of the throat at this age is ordinarily a general 
pharyngitis, the tonsils participating in the morbid state. 

Pharyngitis is primary or secondary. The secondary form occurs in 
measles, scarlet fever, bronchitis, croup, pneumonitis, and occasionally in 
other affections. As these diseases are common, physicians are oftener 
called to treat patients who have the secondary form than the primary. 
Eilliet and Barthez met eighty-three secondary to sixteen primary. 

Anatomical Characters. — The pathological anatomy of pharyngitis 
is ascertained by depressing the tongue and inspecting the fauces. The 
membrane lining the fauces is seen to be redder than in health, and pre- 
senting a more or less swollen appearance, according to the intensity of the 



CAUSES SYMPTOMS PROGNOSIS. 579 

inflammation. In idiopathic pharyngitis, the fauces commonly have a 
bright-red hue, almost like that of arterial blood. If, on the other hand, 
the in'flamraation occurs in connection with a constitutional malady, the 
hue is apt to be darker. In grave cases of scarlet fever or measles, it is 
sometimes even livid, ijidicating a vitiated state of the blood, a condition 
of real danger. The tonsils are tumefied so as to project, though not to 
the extent which we often observe in the adult. They are also less firm 
than in the normal state. The follicles of the throat are enlarged and 
active, pouring out a muco-purulent secretion. This is sometimes seen in 
a layer over the tonsil or the posterior portion of the fauces. In a case 
of primary pharyngitis examined after death by Rilliet and Barthez, the 
tonsils were softened, infiltrated with pus, and slightly enlarged. A layer 
of bloody mucus lay on the pharynx, and the pharyngeal surface was dark- 
red, thickened and granular. The submaxillary glands were also swollen 
and somewhat softened. 

If the inflammation is intense, the deepseated portion of the tonsil 
becomes involved, and even sometimes the adjacent connective tissue. In 
most cases, by applying the finger in the hollow below the ears, the tonsil 
can be felt. In severe cases, also, the submaxillary glands are tumefied. 

Causes. — The usual cause of primary or idiopathic pharyngitis is expo- 
sure to cold. It also occasionally occurs from the use of drinks too hot or 
containing some irritating substance. I have met it in the most intense 
form caused by swallowing boiling water, and, in one case, from acetic acid 
taken through mistake. When it occurs from the eruptive fevers, it is 
part of a more extensive mucous phlegmasia, although the inflammation 
is often, as in scarlet fever, more intense in the pharynx than elsewhere. 

Symptoms. — Tenderness of the pharynx, and pain on swallowing, an- 
nounce pharyngitis. These symptoms are not so readily detected in infancy 
as in childhood. They are not always proportionate to the intensity of 
the inflammation. The tongue is slightly furred; there is thirst, and the 
appetite is more or less impaired. The breath is foul, but not fetid ; the 
respiration is normal, or but slightly accelerated ; cough is sometimes 
present, sometimes absent. When present, it is due to extension of inflam- 
mation to the u^Dper part of the larynx, or to the collection of mucus 
around the aperture of the glottis. 

When the tonsils are considerably enlarged, and the adjacent parts much 
swollen, the voice is sometimes much altered, presenting a nasal character. 
The pulse in pharyngitis is accelerated, and the temperature of the surface 
elevated according to the severity of the inflammation. 

Pkognosis. — In mild cases of pharyngitis convalescence commences 
within a week. If the inflammation is dependent on a constitutional aflec- 
tion, it may continue a much longer time, especially if the glands of the 
neck and the connective tissue are much involved. The prognosis of 
secondary pharyngitis is less favorable than that of the primary form. In 



580 SIMPLE PHARYNGITIS. 

fatal cases there is usually a vitiated state of the blood, either from the 
coexisting constitutional disease, or from previous cachexia. The younger 
the child, also, the less favorable the prognosis. 

Pharyngitis may, however, become dangerous from complications to 
which it gives rise. The proximity of the inflammation to the brain, or 
its effect upon the cerebro-spinal axis through the medium of the nerves, 
sometimes gives rise to clonic convulsions. In a recent case of primaiy 
pharyngitis in my practice, repeated and violent convulsions occurred in 
an iufaut, about one year old, from this cause. They commenced at the 
inception of the inflammation, and constituted the only real danger. 
Pharyngitis may interfere materially with nutrition in consequence of the 
dysphagia, but iu most cases of primary pharyngitis this symptom does not 
continue sufBcieutly long to endanger the life of the patient. In grave 
constitutional affections, as scarlet fever, the difficulty of swallowing, and 
the consequent innutrition, augment the danger. As regards, therefore, 
the prognosis in simple pharyngitis, whether primary or secondary, it may 
be stated as a rule, that it is not, per se, a fatal disease, but is only so from 
complications, or from aggravating the primary malady with which it is 
associated. 

Diagnosis. — This is never difficult provided attention is directed to the 
throat ; but the physician often fails to discover it at his first visit, from 
neglecting to examine this part. In many cases the local symptoms are 
not well-marked, and in the absence of these the febrile reaction may at 
first be referred to some other cause than the true one. Inspection not 
only reveals the presence of inflammation, but enables us to determine 
whether it is simple pharyngitis, or diphtheritic, or ulcerative. In some 
instances, simple pharyngitis resembles diphtheritic, from the presence of 
confervoid growths upon the inflamed surface, usually the leptothrix buc- 
calis. The differential diagnosis is based on the easy removal and soft 
pultaceous character of the conferva', and the appearance under the mi- 
croscope. 

Treatment. — 3Iild cases of simple pharyngitis require little treatment. 
With moderate counter-irritation over the throat, and the use of laxative 
medicines, the inflammation soon subsides. The liuimentum camphorte 
may be occasionally rubbed over the throat, and retained upon it by flan- 
nel. The effect is increased by the application, once or twice daily, of 
mustard or tincture of iodine, or by adding to the liniment a little volatile 
liniment or turpentine. Mucilaginous and refrigerant drinks, with a light 
diet, suffice to complete the cure. 

In the severe form of idiopathic pharyngitis more active measures are 
required. The bowels should be freely opened, warm mustard pediluvia 
occasionally employed, and the head .be kept cool. If the patient is robust, 
in the fii'st stages of the disease, and there is threateuing of cerebral 



PERI-PHARYNGEAL ABSCESS. 581 

complication, it is proper to apply one or more leeches to the temples or 
neck; but cases requiring such depletion are exceptional. 

Diaphoretics and sometimes cardiac sedatives are indicated, such as 
liquor ammonite acetatis, spiritus setheris nitrosi, ipecacuanha, tartrate of 
antimony and potassa, aconite, and veratrum viride. Medicines of this 
kind may be variously combined according to the age and condition of the 
patient, and the severity of the disease. Saline laxatives are also in some 
cases useful. 

As the symptoms abate, the intervals between the doses may be in- 
creased. In those cases of severe idiopathic pharyngitis attended by pain 
in deglutition, moderate but constant counter-irritation should be employed 
over the seat of inflammation. An excellent application, and one much 
used in families, is a slice of fat salt pork, cut as thin as possible, stitched 
on a single thickness of muslin, and applied from ear to ear. It is better, 
usually, to sprinkle more salt upon it, and sometimes powdered camphor. 

In cases of much tenderness and dysphagia great relief is often obtained 
by emollient poultices applied over the throat. Mustard or iodine may 
also be occasionally employed in addition if there is not already sufficient 
counter-irritation. 

Topical treatment of the 'pharynx is recommended by most authors. 
Rilliet and Barthez use for this purpose nitrate of silver or powdered alum. 
The former has been most employed by physicians. It may be applied in 
the proportion often grains to the ounce, two or three times daily. I have 
commonly prescribed the liquor ferri subsulphatis mixed with three or four 
times its quantity of glycerin, for application to the inflamed part, and 
with a good result. 

Gargles, which we so often prescribe in the pharyngitis of adults, cannot 
be satisfactorily employed in infancy and early childhood. 

The treatment of secondary pharyngitis will be described in connection 
with the treatment of the diseases which it complicates. Suffice it here 
to say that this form of inflammation must not be treated by those de- 
pressing remedies which are useful in certain cases of idiopathic pharyn- 
gitis. 

Pseudo-membranous pharyngitis, or diphtheria, has been described in 
another part of this treatise. 

Peri-Pharyngeal Abscess. 

Every practitioner should bear in mind the fact that an abscess occa- 
sionally forms between the pharynx and vertebral column (retro-pharyn- 
geal), or upon the sides of the pharynx in the submucous connective 
tissue. This constitutes a disease which is apt to be fatal, but which can 
ordinarily be promptly relieved by the surgeon. 

Yet, if we look over the records of peri-pharyngeal abscess, we shall 



582 PERI-PHARYXGEAL ABSCESS. 

see that in a large proportion of published cases, the disease was supposed 
to be something else, and so treated until its nature Avas revealed by post- 
mortem examination. The most complete monograph on this disease with 
which I am acquainted was published by Dr. Allin, of this city, in the 
N. Y. Jour. of. Med. for November, 1851, under the title of retro-pharyn- 
geal abscess. To this paper I am largely indebted for facts. 

Age — Cause. — This disease may occur at any age, but it is most com- 
mon in infancy and childhood. It is more frequent in the first year of 
life than at any other period. Of the cases collated by Dr. Allin, in 
which the age is stated, twenty were under ten years, while the number 
for all other ages was twenty-one. This disease arises in some patients 
from caries of the vertebral column, and, in others, from inflammation, 
commencing with the mucous membrane of the pharynx and extending 
to the submucous connective tissue. Whichever the cause, there is usu- 
ally a scrofulous or reduced state of system. 

Writers describe two kinds of peri-pharyngeal abscess, the primary and 
secondary. This distinction is based on the fact, whether or not the 
inflammation which leads to the abscess is dependent on an antecedent 
pathological state. 

In the primary form the cause is usually atmospheric, or it is some 
irritating substance which has been swallowed, and which, lodging in the 
pharynx, produces pharyngitis. 

The cause is mentioned in twenty cases of the primary form, collated 
by Dr. Allin, as follows : Exposure to cold, ten cases ; lodgement of bone 
in pharynx, eight cases; blow with a fencing-foil, one case. In the last 
case the button of a fencing-foil passed through the right nostril into the 
pharynx. 

The secondary form occasionally occurs after measles and scarlet fever. 
The inflammation of the pharynx, common in those diseases, extends to 
the subjacent connective tissue, and, aided by the dyscrasia of the patient, 
becomes suppurative. Such cases have been observed by Rilliet and 
Barthez. The most common cause of the secondary form is, however, 
caries of the vertebral column. 

When thus occurring it is similar, both as regards cause and nature, to 
lumbar abscess. It would follow the same chronic course, and would 
properly be described in connection with it, were it not for its proximity 
to the air-passages, which renders the disease so rapid and fatal. In a 
few recorded cases the abscess has been a sequel of erysipelas. In nine- 
teen cases of secondary abscess, in Dr. Allin's collection, the cause is 
assigned as follows : Erysipelas of face, two ; inflammation following a 
fall upon the inferior maxilla, one ; after cerebritis, one ; syphilis, four ; 
caries of the cervical vertebra, six ; scrofula, five. 

The proximate cause of peri-pharyngeal abscess is believed by Mr. 
Fleming {Dublin Jour, oj Med. Sci., vol. xvii) to be in some instances 



ANATOMICAL CHARACTERS — SYMPTOMS. 583 

inflammation of small lymj)hatic glands lying in the connective tissue 
external to the pharynx. After remarking that two cases which he re- 
ports lend confirmation to this view, he continues : " That those glands 
are only occasionally found in this situation, I admit, and hence, probably, . 
the rare occurrence of this particular form of disease, but that they exist 
more frequently than is generally imagined, I am equally certain." The late 
Prof. Geo. T. Elliot has recorded the case of an infant of seven months 
(Obstet. Clinic, N. Y., Appleton & Co., 1868) in whom peri-pharyngeal 
abscess immediately followed, and was apparently due to parotiditis. 

In rare instances the abscess, or the local disease which leads to it 
appears to exist from birth. Thus, Dr. E. O. Hocken relates, in the 
Frov. Med. and Surg. Jour., 1842, the history of an infant who died at 
the age of nine weeks. It had always, when taking the breast, thrown 
back its head as if nearly suffocated. The walls of the abscess were thick 
and firm, described by the writer as cartilaginous. Occasionally there is 
no apparent cause of the abscess, except the cachectic state. 

Anatomical Characters. — The seat of the abscess is not the same in 
all cases. The swelling can ordinarily be seen on examining the fauces, 
but occasionally it is so low as to be really peri-oesophageal, and, therefore, 
invisible. The size of the abscess varies ; sometimes it is large, pressing 
inward the wall of the pharynx even against the velum palati and into 
the posterior nares, if the abscess have a high location, or, if lower, against 
the larynx, so as to embarrass respiration. Sometimes the abscess is so large 
or has such lateral extension that there is external swelling along the side 
of the neck. In a few cases on record the pus, instead of being discharged 
into the pharynx, made its way down the neck between the muscles and 
the connective tissue to the pleural cavity, which it entered, producing 
fatal pleuritis. 

The walls of the abscess have been found in a different state in different 
cases. Sometimes the sac, at the projecting point, is so thin that it seems 
as if there might have been a spontaneous cure, could life have been pre- 
served a few hours longer. In other cases the sac is so thick and firm that 
its rupture, for many days, would be impossible. 

Symptoms. — The precursory symptoms differ in different cases, accord- 
ing to the nature of the cause, whether it be pharyngitis, glandular in- 
flammation, or vertebral caries. If the abscess proceed from caries, it is 
preceded by deepseated and protracted pain, greatly increased by move- 
ments of the head. 

The patient with this disease is restless, his mouth hot and dry ; tongue 
furred ; deglutition more or less difficult. Sometimes after suppuration has 
occurred there are alternations of heat and chills. The symptoms indicate 
approximately the seat of the inflammation, but on examination we do not 
find that degree of redness and swelling of the mucous surface which we 
had been led to expect. The tissues which are chiefly involved in the in- 



584 PERI-PHARYNGEAL ABSCESS. 

flamination, being submucous, are hidden from view. We observe redness 
of the pharynx, but it is disproportionate to the intensity of the symptoms. 
Sometimes there is a sensation of chilliness through the entire period of 
the abscess, though greater at one time than at another, and occasionally 
convulsions occur, especially in young infants. In ordinary cases the em- 
barrassment of respiration is one of the first and most conspicuous of the 
symptoms, and it is the cause of the chief danger. It becomes more and 
more marked as the abscess increases. It is noticed both during inspira- 
tion and expiration. The dysphagia also increases, sometimes to such a 
degree that drinks are taken with difficulty, and solid food refused. The 
respiratory symptoms bear considerable resemblance to those in protracted 
laryngitis, for which this disease has been mistaken. While the respiration 
becomes impeded or whistling, the voice is also feeble or indistinct, from 
the pressure of the tumor. 

But the symptoms described above are not all present in every case. 
They vary according to the size and location of the abscess, whether it be 
high or low, posterior or lateral. I have met the disease in a child old 
enough to express its subjective symptoms, in whom there was little or no 
dysphagia, and others report similar cases. When the tumor has attained 
such a size as to produce well-marked symptoms and jeopardize the life of 
the patient, it, or a part of it, can ordinarily be seen on depressing the 
tongue, but usually its location and condition can be better ascertained by 
exploration with the finger. The dyspnoea increases as the abscess en- 
larges, and, after a time, unless it bursts spontaneously or is opened by the 
surgeon, imperfect oxygenation of the blood results. In some patients 
paroxysms of dyspnoea occur, so as to threaten immediate suffocation; 
coughing or attempts to swalloAV induce these paroxysms, and the patient 
is forced to remain in an erect or semi-erect posture. The tongue is pro- 
truded, the head thrown back, the pulse is frequent and rapid, the limbs 
become livid and cool, and finally death occurs from apnoea. Occasionally, 
when death seems inevitable, the abscess gives way by the struggles of the 
child, and the patient is restored to health. In rare cases the result is dif- 
ferent. The trachea and bronchial tubes are deluged by the purulent dis- 
charge, and immediate suffocation occurs. The following was an example : 
In May, 1871, a boy two years and five mouths old, was brought to the Clinic 
at Bellevue, who had had the symptoms of an abscess for three months. 
The head was carried on one side, its rotation caused pain, and a laryngeal 
rale accompanied respiration. The upper part of the tumor could be de- 
tected by the finger, but, on account of its low location, it was impossible 
to open it with the bistoury. The temperature was 103°, pulse 156. The 
case was kept under observation, but in a few days the dyspnoea suddenly 
became so urgent that death was imminent, when the attending physician 
of the class. Dr. Swezey, broke the abscess with his finger, and pus Avas 
ejected on the floor; death, however, occurred almost immediately. 



SYMPTOMS. 585 

A correct appreciation of the symptoms and the nature of peri-pharyn- 
geal abscess will be best obtained by relating a case. I select the follow- 
ing from the Transactions of the London Pathological Society, October 20th, 
1846 : 

A female infant died at the age of seven months, having had difficult 
breathing three weeks, and extreme dyspnoea during the last days of life. 
The dyspnoea was constant, and was aggravated by mental excitement, by 
movements of the body, and by exposure to cold. During the paroxysms, 
a peculiar, croupy sound accompanied inspiration. There was no dysphagia 
through the entire sickness, and death occurred from apnoea. 

The sac of the abscess was of the size of a pigeon's egg, and was situated 
between the upper cervical vertebrse and the back of the pharynx. The 
abscess was flattened in front, so as not to cause any material prominence 
of the wall of the pharynx. From the sac a second small cyst extended 
forward, forming a nipple-like swelling in the pharynx, which completely 
closed the orifice of the glottis. Its aperture of communication with the 
body of the abscess admitted the point of the little fiugei", and the whole 
swelling was freely movable and perfectly translucent at its extremities 
and sides. The abscess might have been easily punctured, with probably 
the preservation of life. 

The duration of this malady is very different, according to the severity 
of the inflammation, the rapidity with which the abscess enlarges, and the 
direction which it points. A lateral or downward extension is not so im- 
mediately dangerous to life as the anterior. 

The time when the abscess begins to form cannot be precisely ascer- 
tained, and most writers, in determining the duration of the disease, com- 
pute from the first appearance of symptoms which are referable to the 
pharynx, Dr, J, Bryne relates, in the Amer. Jour, of Med. Sci., 1838, a 
fatal case in which the disease had apparently continued only about one 
week. The patient was an infant one year old, and died of apnoea. The 
abscess was large, extending from the base of the skull to the thorax, and 
pressing both on the larynx and trachea. M. Besserer (Archiv. Gen. de 
Med., 1840) gives the history of an infant four months old, who died in 
the same way after thirteen days. An infant nine months old, whose case 
was published by Dr, W. C. Worthington, in the Frov. Med. and Surg. 
Jour., 1842, lived nine days. The abscess occurred from exposure to cold ; 
the patient was treated for croup, and died from suffocation. The anterior 
wall of the abscess was very thin. Since the first edition of this book was 
published, I have met four patients with this disease in whom the pus was 
evacuated when the dyspnoea had become urgent. In two the symptoms 
indicated a continuance of the disease from two to four Aveeks, and in the 
third case four months. The fourth case is interesting on account of the 
short duration of the severe symptoms. The following is the record of it. 



586 PERI-PHAEYNGEAL ABSCESS. 

M. E., aged 7 months, female, nursing, inmate of the Catholic Foundling 
Asylum, was observed to have difficult breathing for the first time, on 
March 28th, 1875. Since about March 8th, some swelling had been noticed 
along the side of the neck, but it gave rise to no marked symptoms and 
she had not seemed ill, till the obstruction in the respiration commenced. 
At my visit on the evening of the 28th, the infant was pointed out to me 
as in a dying condition. She was lying in a state of stupor, pallid, and 
gasping for breath, with a temperature of 103°, and very feeble pulse, 
numbering about 200 per minute. On carrying the finger into the throat 
an abscess could be readily detected, situated in the walls of the pharynx 
on the left side posteriorly. This was easily opened by a curved bistoury, 
around which adhesive plaster was wound to within half an inch of the 
point. The breathing immediately began to improve. On the following 
day the infant was playing in the mother's lap, with a pulse of 140, but a 
normal temperature. With the use of cod-liver oil and the syrup of the 
iodide of iron, its health was soon fully restored. 

When the abscess grows slowly, and presses lightly on the air-passages, 
the case may continue for months. Such a one was observed by Professor 
Willard Parker (Allin). This infant was one year old ; it suflTered from 
l^haryngeal symptoms nine months, was treated for tonsillitis, and death 
occurred as usual from apuoea. The abscess was two inches long, and there 
was no disease of the vertebrje. The same surgeon saved the life of an- 
other patient four years old, in whom the disease was chronic, by punc- 
turing the abscess ; and Professor Post, of this city, also treated successfully 
a case which had continued three months. (Allin.) 

Diagnosis. — The diagnosis of this disease is ordinarily not difficult, 
provided the physician examine carefully and bear in mind the occasional 
occurrence of such an abscess. In a large proportion, however, of the re- 
corded fatal cases, the true nature of the disease was not recognized during 
life. Especially is the diagnosis difficult when the cerebro-spinal system 
is early implicated, and symptoms arise which divert attention from the 
throat to the brain. 

The diseases with which peri-pharyngeal abscess is most frequently con- 
founded are laryngitis and simple but severe pharyngitis. From laryn- 
gitis, for which it has been most frequently mistaken, it may be distin- 
guished by the dysphagia and by the character of the initial symptoms. In 
laryngitis there is usually the peculiar cough from the first or very early, 
while in abscess there is a period of several days or even weeks before res- 
piration is materially afl^ected. 

In abscess pressure of the larynx backward is badly tolerated, greatly 
increasing the dyspnoea, while in pharyngitis and croup this effect is not so 
marked. In abscess the horizontal position aggravates the dyspnoea, but 
not in pharyngitis and croup. The character of the voice will also aid in 



PROGNOSIS TREATMENT. 587 

diagnosticating abscess from laryngitis, since in the former it is apt to be 
nasal, and in the latter hoarse or whispering. The decisive test is afforded 
by inspection and digital exploration. The tumor is seen, or, if situated 
too low to be seen, is felt, upon tlie walls of the pharynx. 

If the symptoms of abscess are masked by those arising from the cerebro- 
spinal system, as by convulsions, the priority of the pharyngeal symptoms 
will serve to aid in determining the true disease. 

In a case of suspected abscess the physician should not only carefully 
inspect the fauces, but should employ digital examination. The finger 
will often detect fluctuation when no evidence of an abscess or uncertain 
evidence is presented to the eye. 

Prognosis. — With proper treatment the result is usually favorable, but, 
if the disease is not recognized, the majority die. In Dr. Allin's cases, of 
those under the age of twelve years nine died, while ten recovered by the 
opening of the abscess by the lancet, trocar, or finger, and one by its 
spontaneous rupture. 

If the abscess is due to disease of the spinal column, death may occur 
immediately after the sac is opened, the caries of the intervertebral carti- 
lages producing, according to Dr. Allin, dislocation of the vertebrae. Death 
may also occur, though rarely, from pleuritis, in consequence of the burst- 
ing of the abscess into the pleural cavity. Even in caries, if the sac is 
properly opened, and if need be reopened, recovery is possible, as in a case 
treated by Prof. Post. 

Treatment. — The proper treatment of peri-pharyngeal abscess is sim- 
ple, consisting in breaking or puncturing the sac by the finger, the lancet, 
bistoury, or pharyngotome. Each method has been successfully employed. 
In the majority of cases the proper way to open the abscess is by the 
ordinary curved scalpel or bistoury, which should be covered by a strip 
of adhesive plaster to within a half inch of the point. If the abscess is 
post-pharyngeal, it should be opened in the median line. A single in- 
cision suffices to evacuate the pus. If the abscess points or is elastic, there 
is little danger of wounding any important vessel or producing dangerous 
haemorrhage if the operation is properly performed. It may be necessary 
to open the abscess more than once, as in a case reported by Dr. Post, 
and another which I saw with Dr. Livingston, of this city. In certain 
cases, when the knife can not be readily employed, the abscess may be 
opened by pressure with the finger nail or the edge of a teaspoon. 

Patients with this disease ordinarily require constitutional treatment, 
especially the use of tonics, ferruginous and vegetable. The citrate of 
iron and quinine, the citrate of iron and ammonia, and in strumous cases 
the syrup of the iodide of iron with cod-liver oil, are eligible preparations. 
Nutritious diet and often alcoholic stimulants are required. 



588 OESOPHAGITIS. 



Qjsophagitis. 



Disease of the oesophagus in infancy and childhood is comparatively 
rare, inflammation being the most frequent affection of this portion of the 
digestive tube in these periods, and, indeed, the only one which claims 
attention. It is most common in infants under the age of three or four 
months, who are deprived of the breast-milk, and are given a diet which 
is with difficulty digested, and perhaps taken too hot or too cold. It is, 
therefore, most frequent in foundling hospitals. I have frequently observed 
it in the Infant's Hospital, and the Nursery and Child's Hospital, of this 
city, chiefly at the autopsies of bottle-fed infants, under the age of six 
months, whose symptoms had indicated disease or derangement of the 
digestive function. Many of them had diarrhoea, and died in a state of 
emaciation. CEsophagitis in these cases was associated with simple or 
gangrenous stomatitis, thrush, or with gastritis or entero-colitis. Some- 
times all these inflammations coexisted. In a few cases the confervoid 
growth of thrush had extended from the mouth to the oesophagus. It 
occurred in small hemispherical masses, scarcely as large as a pin's 
head. Swallowing corrosive or strongly irritating substances, as the acids 
or alkalies, is an occasional cause of oesophagitis, the irritant at the same 
time producing stomatitis and gastritis. 

Anatomical Characters. — The inflamed surface sometimes presents 
a uniformly injected appearance. Usually, however, there is greater in- 
tensity of inflammation in streaks or patches than over the surface gener- 
ally. I have frequently observed at autopsies a greater degree of inflamma- 
tion in the lower than upper half of the oesophagus, even when the infant 
had stomatitis at the time of death. 

CEsophagitis occurring from faulty regimen or anti-hygienic conditions 
is not accompanied by as much thickening of the walls of the tube as often 
occurs in some other portions of the digestive canal, as, for example, in the 
colon. In diphtheritic inflammation of the oesophagus there are more sub- 
mucous infiltration and thickening of the mucous membrane than in simple 
oesophagitis. 

Occasionally ulcerations of the oesophageal mucous membrane are ob- 
served in the lower part of the tube, and Billard describes the ulcerative 
form of oesophagitis. At the first autopsies at which I observed these ulcers, 
I supposed that they were pathological, and indicated a severe grade of in- 
flammation ; but a more extended observation has convinced me that they 
are usually post-mortem, and are not at all dependent on inflammation of 
the oesophagus. The solvent power of the gastric juice not only causes 
ulceration in the stomach, but entering the oesophagus may and not infre- 
quentl}'^ does produce a solvent action on the mucous tissue there. At 
the meeting of the London Pathological Society, March 4th, 1852, Dr. 
Graily Hewitt presented a specimen in which the gastric juice had not 



INDIGESTION. 589 

only eaten entirely through the coats of the oesophagus an inch above the 
stomach, but liad even attacked the left lung. Over the age of six months 
inflammation of the oesophagus is rare. 

The symptoms of oesophagitis, in those young and emaciated infants in 
whom it ordinarily occurs, are not well-pronounced. If they have pain 
in deglutition, or tenderness on pressure over the oesophagus, it is not ap- 
parent. Nor have they seemed to me to vomit oftener than other infants of 
this class who suffered from indigestion and gastro-enteritis, without oesoph- 
agitis. It is, therefore, difficult to diagnosticate oesophagitis. It is, accord- 
ing to my observation, oftener present than absent in spoon-fed infants of 
three months or under who have persistent stomatitis and entero-colitis. 

Treatment. — In the a?,sophagitis of foundlings and ill-nourished infants, 
which arises, as has been stated, from faulty regimen, no treatment is re- 
quired apart from that designed to relieve the stomatitis or entero-colitis 
with which it exists. Attention must be directed mainly to the diet and 
hygienic management. The remedial measures are more fully detailed in 
our remarks on entero-colitis. QEsophagitis produced by swallowing cor- 
rosive or highly irritating substances requires the same treatment as in the 
adult, namely, poultices, demulcent drinks, perhaps leeches, etc. 



CHAPTER VI. 

INDIGESTION, CONGESTION OF STOMACH, GASTKITIS, FOLLICU- 

LAK GASTRITIS, DIPHTHEEITIC GASTRITIS, POST-MORTEM 

DIGESTION, SOFTENING. 

Indigestion is much more common during infancy than in any other 
period of life. While the digestive organs in the adult easily assimilate 
a great variety of food, it is necessary for the well-being of the infant that 
its diet be simple and carefully prepared. Departure from this rule leads 
to indigestion and ulterior diseases. 

After the age of two years a mixed diet is readily assimilated, the di- 
gestive function less frequently disordered, and indigestion presents few 
peculiarities to distinguish it from that of the adult. 

Indigestion in some children is habitual ; in others the digestive process 
is ordinarily well performed, but, from some temporary derangement of 
system or error of diet, an acute attack of indigestion occurs. Hence, 
two forms of this ailment may be described: first, acute, referring to tem- 
porary attacks; secondly, chronic, referring to the habitual state. 

Causes. — The causes of indigestion are twofold : first, the condition of 
the digestive function independently of the aliment ; secondly, the un- 



590 INDIGESTION. 

wholesome or improper character of the ingesta. Anything which lowers 
the vital powers may be a predisposing cause of indigestion, by impairing 
the functions of some of the organs which assimilate the food. Impure 
air and personal uncleanliness, protracted hot weather, and previous dis- 
ease, are among the common predisposing causes. The strong country 
child can thrive upon a diet which, given to the more feeble child of the 
city, would produce deleterious results. Dui'ing the summer months it 
often happens that an infant in the city cannot digest properly any food 
given to it excepfthe mother's milk ; and from this results much of the in- 
fantile sickness and mortality which make this season of the year so much 
dreaded by parents. There is a natural difference in children, as regards 
liability to disordered digestion. Some do well upon a diet which given 
to others similarly situated occasions vomiting, gastralgia, and flatulence. 

In the majority of cases of indigestion, however, the fault does not exist 
in the child. It is fed too often or irregularly, or upon a diet that is un- 
wholesome or indigestible. It is well known that the milk of the mother 
or the wet-nurse is liable to changes which render it for the time unsuitable 
for the infant. Her food may be of such a quality, or her mind so ex- 
cited, or some function of her system so disordered, as to effect a temporary 
change in the constitution of the milk. The occurrence of the catamenia, 
or of gestation, in mothers who are suckling, not infrequently produces 
this unfavorable result. 

Indigestion is most common in those infants who, deprived of the mother's 
milk, are intrusted to wet-nurses, or fed from the bottle. The milk of the 
wet-nurse, from not agreeing with the age of the infant, from irregularity 
in her mode of life, from the acescent nature of her food, or from other 
causes which are not appreciable, may disagree with the infant, and be 
imperfectly digested. 

The most common cause of indigestion in the infant is artificial feeding. 
This, in the cities, is productive of a great amount of gastric and intestinal 
derangement and disease. The younger the inflmt, the less frequently 
does it thrive if brought up by hand. 

Whatever care may be bestowed in the preparation of its food, whether 
cow's or goat's milk, or farinaceous substances be used, there is seldom that 
healthy nutrition which is observed in infants who receive the natural ali- 
ment. The "swill milk" in common use among the poor families of this 
city is totally unfit for children of any age, and is apt to produce flatu- 
lence, acidity, and indigestion. Acute indigestion occurs in children of 
any age from food unsuitable in quality or quantity, which produces gas- 
tralgia and other symptoms to be detailed hereafter. Those who suffer 
habitually from mal-assimilation are especially liable to such acute at- 
tacks. 

In the period of childhood, chronic indigestion is much less frequent 
than in infancy, but children are, perhaps, more subject than infants to 



SYMPTOMS. 591 

the acute form. This is induced by ingesta taken in too large quantity, 
or of a kind which is with difficulty digested. Cherries, currants, raisins, 
the parenchyma of oranges and lemons, dried fruits and confectionery, 
which are so often heedlessly given to children, are common causes of acute 
attacks of indigestion. These substances, being but partially digested or 
not at all, and sometimes accumulating for days in the stomach or intes- 
tines, may lead to a very serious and dangerous condition. 

Symptoms. — The nursing infant, if the milk continually disagree with 
it, is fretful. It has a discontented aspect. It seldom 'smiles, and is not 
amused by playthings, or is only amused for a short thne. Its features are 
pallid, and bear the appearance of faulty nutrition. Its body and limbs 
are more or less wasted, or are soft and flabby. Vomiting is frequently 
present, and sometimes a large mass or masses of caseum are ejected, which 
have evidently lain a considerable time in the stomach. The bowels may 
be constipated or loose, and the evacuations are unhealthy. This state of 
the infant continuing prevents the necessary rest of the mother, and may 
affect unfavorably her health, so as to reduce the quantity of her milk, or 
render it still more unwholesome. 

In addition to the habitual indigestion, these infants sometimes have 
acute attacks, similar to the acute dyspepsia of adults, and which have 
been described by writers as gastralgia or enteralgia. Their countenance 
indicates suffering ; they utter sharp cries, and their thighs are drawn over 
the abdomen, indicating the seat of the suffering. Flatulence is common. 
By vomiting or an evacuation from the bowels, the offending substance is 
removed, and the pain subsides. 

Indigestion in the spoon-Jed infant is similar to that in the infant who 
nurses, except that it is oi'dinarily accompanied by symptoms of greater 
gravity and j^ersistence, and there is in the spoon-fed more liability to the 
acute attacks. 

In those who have advanced beyond the age of infancy, chronic indi- 
gestion is less frequent than in infants, but as the diet of such children is 
prepared with less care, and is less restricted, they are very liable to attacks 
of temporary indigestion. These come on suddenly, and sometimes are so 
severe as to endanger life. The child, previously well, is suddenly seized 
Avith languor; the pulse becomes accelerated, the face flushed, and surface 
hot. Drowsiness compels him to seek the bed, where he lies with his eyes 
shut. He sometimes has headache, and a sensation of oppression in the 
epigastrium. The nervous system is not unfrequently affected, as shown 
by tenderness of a neuralgic character of the body and limbs, sudden 
twitching of the limbs premonitory of convulsions, and occasionally severe 
and repeated convulsions. These alarming and really dangerous symp- 
toms speedily subside on the removal of the cause. One of the most severe 
attacks of eclampsia which I have seen occurred in a boy eight or ten years 
old, induced by swallowing the parenchymatous portions of oranges which 



592 IXDIGESTIOX. 

he had been in the habit of eating, and which had accumulated in the 
stomach and intestines. The expulsion of the offending substance gave 
immediate relief. 

Sometimes, but not often, the symptoms of acute indigestion closely re- 
semble those of pneumonitis. For example, an infant, whom I once treated, 
was seized at night with fever, hurried respiration, and the expiratory 
moan, which some writers consider pathognomonic of pneumonitis or pleu- 
ritis. These symptoms subsided when the bowels were freely opened, and 
currants, which had been eaten the previous day, were expelled. 

As the child advances in years and its general health improves, the di- 
gestive function is less frequently disturbed. After the age of three or four 
years indigestion is much less frequent than in infancy and early child- 
hood. 

Indigestion leads to some of the most common and serious affections of 
early life. In the inf\int, if it continue a considerable time, inflammation 
of the buccal, oesophageal, or gastric mucous membrane, or of some part 
of the intestinal tract, ordinarily occurs. In the young infant thrush soon 
makes its appearance, and, whatever the age, the cachexia which results 
from continued indigestion increases the liability to organic maladies. 
Eclampsia is the most serious, and at the same time a frequent, result of 
temporary or acute indigestion. 

Prognosis. — In simple indigestion this is good. It is doubtful or un- 
favorable when ulterior diseases occur, and in proportion to their gravity. 

Treatment. — The first indication in treatment is obviously the removal 
of the cause. In acute indigestion, when there is reason to believe that 
there is some offending substance in the stomach or intestines, if the 
symptoms occur soon after the substance is taken, an emetic may be ad- 
ministered, and ipecacuanha, in syrup or powder, is safe and usually 
efficient. If several hours have elapsed a purgative should be given, as 
castor oil, either alone or in combination with syrup of rhubarb. 

If the symptoms are urgent, especially if convulsions are threatened, 
Ave should not wait for the slow action of a purgative, but should resort 
to enemata to open the bowels. Sometimes the pain in acute indigestion 
is such as to require the use of opiates. In the infant there is often an 
excess of acid in the stomach and intestines, which is best treated by 
alkaline remedies, as lime-water in combination with the opiate. The 
following mixture will be found useful in such cases: 

R. Tinct. opii, or liq. opii compos., gtt. xij. 
Magnes. calcinat., gr. xij. 
Sacch. alb., ^ij. 
Aq. anisi, §iss. Misce. 
Do?c, the bottle being first shaken, one teaspoonful from two to four hours to a 
child a year old. If there is much pain, U is well to add a little chloroform or 
HoU'man's anodyne to the mixture. 



TREATMENT. 593 

Or the following mixture : 

R. Tinct. opii, or liq. opii compos., gtt. xij. 
Bismuth, subnitrat.. ^iss. 
Mistur. cretffi, §iss. Misce. 
Shake bottle thoroughly and give one teaspoonful. 

If in the acute indigestion of infants there is diarrhoea, the camphor- 
ated tincture of opium, in combination with chalk mixture, may be given, 
fifteen drops of the one to a teaspoonful of the other, or the above mix- 
ture. Infants, whose diet properly consists largely of milk, digest with 
most difficulty the caseum, which is apt to pass the bowels in an imper- 
fectly digested state, or to collect in a large and firm mass in the stom- 
ach, causing gastralgia and rendering the child fretful till it is vomited. 
I have elsewhere recommended, as important to prevent these attacks of 
acute dyspepsia, the use of the upper third of the milk, which contains 
less than the average caseum, and the addition of an alkali to the milk, 
which retards the coagulation till it begins to be acted upon by the gastric 
juice, and tends to prevent the formation of large and firm caseous coag- 
ula in the stomach. 

In chronic indigestion the means of relief are different. They are two- 
fold : first, as regards change of diet; secondly, measures to improve the 
digestive function. Spoon-fed infants, suffering from habitual indigestion, 
require the utmost care as regards the character of their food, its prepara- 
tion, and the times of feeding. Often it is best, if practicable, to procure 
a wet-nurse, and sometimes removal to a more salubrious locality is fol- 
lowed at once by improvement in the digestive function. If the infant is 
already wet-nursed, the milk should be examined microscopically and 
otherwise, and inquiry should be instituted in reference to the health and 
diet of the wet-nurse. Sometimes a change of wet-nurse is advisable. 
For facts and considerations bearing on this point the reader is referred 
to the chapters relating to regimen. 

Children with chronic indigestion are occasionally much benefited by 
the moderate and judicious use of alcoholic stimulants. They should be 
given sparingly with their food, and should be discontinued as soon as 
the digestive function is fully restored. M. Donne and some other French 
writers recommend the habitual use of wine for infants even in a state of 
health, but there are reasons, moral as well as physical, why alcoholic 
stimulants should only be used as medicines, and not in a state of health. 

If the ease is one of simple or uncomplicated indigestion, tonics, either 
the mineral or vegetable, may be employed. In many instances, however, 
especially in infancy, gastro-intestinal inflammation has supervened, and 
in such cases those tonics should be employed which exert a favorable, or, 
at least, not an uufavoral)]o effect on the hypericmic aud irritable surface 
over which they pass. 

38 



594 ' IXDIGESTIOX. 

When indigestion is simple, or accompanied by no serious complication, 
wine of iron, citrate of quinine and iron, and the elixir of calisaya bark, 
may be mentioned among the safe and efficient agents to improve the 
digestive function. The following is also a good formula for cases of 
simple indigestion : 

R. Ferri et amnion, citrat., gr. xvj. 

Bismuth, et amnion, citrat., gr. xlviij. 
Aquae, ^ij. Misce. 
. Dose, one teaspoonful three or four times daily to a child of two or three years. 

The ferruginous preparations are most efficacious in cases which are at- 
tended by signs of anaemia. 

Among the useful vegetable stomachics and tonics may be mentioned 
the compound tincture of cinchona, compound tincture of gentian, infusion 
of columbo, fluid extract of columbo, and fluid extract of cinchona. 

If chronic indigestion is complicated with gastro-intestinal inflamma- 
tion, subacute or chronic, for this is the form which is usually present, 
there are still certain tonics which may be advantageously administered. 
Columbo and the compound tincture of cinchona are often useful in these 
cases, and of the chalybeates wine of iron or the citrate of iron and am- 
monia may be safely administered. 

I have not alluded to the use of pepsin as a remedial agent in indi- 
gestion. The theory of its employment in atonic states of the stomach is 
good, but physicians in this country have, in most instances, failed to ob- 
serve that benefit from its use which they had been led to expect, and 
which seems to have followed its employment in the practice of some of 
the European physicians. Perhaps the result would have been better had 
fresher and better preparations of pepsin been prescribed. Boudjiult's 
pepsin from Paris has been most used in this country, but the American 
preparations are probably equally good. I have prescribed it in doses of 
two or three grains, several times daily, to foundlings from one to three 
months old, and in proportionate doses to older infants, but I am not able 
to speak confidently of its eflfects, as I have commonly given it with bis- 
muth. 

The American pepsin, prepared under the intelligent supervision of ex- 
perienced chemists, can be obtained in the shops in the form of a powder 
or liquid. From its fre.shne.ss and unobjectionable taste it possesses ad- 
vantages. 

Infants affected with diarrhoea from indigestion often improve under the 
use of powders consisting of equal parts of subnitrate of bismuth and 
pepsin. An infant of three months can take three grains of each every 
three hours. 

Dyspepsia often rapidly disappears by hygienic measures without the 
use of medicines, as by removal from the city to the country, outdoor 



CONGESTION OF THE STOMACH — GASTEITIS. 595 

exercise, or, if the patient is an infant, by being carried into the open air 
daily. In infants, also, marked improvement is often observed on the ap- 
proach of the cool and bracing weather of autumn and winter. 

Congestion of the Stomach. 

Passive congestion of the stomach is described among the diseases of 
this organ by Billard ; but it is a pathological state of little importance in 
itself. It occurs in newborn infants, asphyxiated at birth and with diffi- 
culty resuscitated. In these cases there is generally intense capillary con-» 
gestion throughout the system. The mucous membrane of the stomach is 
injected, but not more than that of the mouth or intestines. If circulation 
and respiration are fully established, this injection of the capillaries sub- 
sides. No treatment is required, except measures to promote the circula- 
tory and respiratory functions. In cyanosis and atelectasis there is often 
general congestion of the capillaries of the systemic circulatory system, on 
account of the obstruction to the flow of blood through the heart in the 
one disease and through the lungs in the other. There is in these cases 
passive congestion of the stomach, but not more than of the other organs. 

Gastritis. 

Inflammation of the stomach, except when produced by the direct con- 
tact of some irritant, is rare in infancy and childhood, independently of 
disease in some other portion of the intestinal tract. Cases have, however, 
been reported in which it was not known that any irritating ingesta had 
been taken, and in which a careful examination revealed a healthy or 
nearly healthy state of other portions of the digestive tube. The subjects 
were, for the most part, young infants. The following is an example re- 
lated by Billard : 

An infant, four days old, remarkable for the color of his face and firm- 
ness of flesh, refused the breast and vomited yellow, acid matter. On the 
following day the vomiting had increased, the legs were oedematous, face 
pale and pinched, respiration difficult, skin cold, pulse slow and irregular, 
and pressure on the epigastric region produced cries indicative of pain. 

Third day : general sinking ; face thin and expressive of great pain ; 
stools natural. 

Fourth and fifth days: condition the same. Death occurred on the 
sixth day, and the autopsy was made on the day following. 

With the exception of slight pneumonitis, no disease was discovered in 
any part of the system besides the stomach. The mucous membrane of 
this organ was intensely vascular near the cardiac orifice and along the 
lesser curvature. It was also tumefied, and could be easily raised with 
the nail. In the remainder of this organ there was strongly marked 
capilliforra injection. 

This case is interesting as showing what may happen, though rarely. 



596 GASTRITIS. 

A nursing infant is seized Avith gastritis without apparently having taken 
any irritating ingesta, and without other disease of the digestive apparatus. 
It is probable, however, that, in cases like the above, the cause, if ascer- 
tained, would be found in the ingesta: perhaps drinks too hot, perhaps 
elements of colostrum, or pathological elements in the milk, w'hich might 
produce gastritis in young infants in whom the mucous membrane is deli- 
cate and sensitive. 

Gastritis is not uncommon in infancy in connection with inflammation 
^)f the intestines. The latter inflammation is sometimes apparently sub-- 
ordinate to the former, and, if such j)atients die, the fatal result is due 
mainly to the gastric disease. 

Cause. — ^Gastritis as I have observed it in infants has been in most 
cases due in great part to the continued use of improper food, of food not 
suitable to the age of the child, and which was, therefore, with diflficulty 
digested. Milk, acid, or otherwise unwholesome, farinaceous substances, 
stale or of an inferior quality and not properly prepared, drinks too hot or 
too cold, may be specified among the causes. Therefore, this disease is 
most common in bottle-fed infants, and is comparatively rare in those who 
receive abundant and wholesome breast-milk. Anti-hygienic agencies, 
apart from the diet, no doubt exert some influence in the production of 
gastritis, as they do of stomatitis. Uncleanliness, and residence in damp 
and dark apartments, or in an atmosphere loaded with noxious gases, pro- 
duce a condition of system which strongly predisposes to these inflamma- 
tions, if, indeed, they may not be enumerated among the direct causes. 

Rilliet and Barthez have called attention to the fact that certain medic- 
inal substances given to children occasionally cause gastritis. They have 
observed this effect from the use of tartar emetic, Kermes mineral, and 
croton oil. Gastritis occurring in this way may or may not be associated 
with inflammation in contiguous portions of the digestive tube. Elsewhere 
I have related a case in which gastro-enteritis occurred in a child nine 
years old, after having taken a considerable quantity of kerosene oil for 
spasmodic croup. 

Inflammation of the stomach is thought by some to accompany measles 
and scai'let fever during the eruptive period, but this opinion is probably 
incorrect. If it occur, it corresponds with the stomatitis and dermatitis 
of those diseases, and disappears as they subside. It is mild, and accom- 
panied by few symptoms. I have, as stated in the remarks on scarlet 
fever, examined in certain instances the stomachs of those who had died 
during the eruptive period of these diseases, and found them free from any 
appreciable inflammatory lesion. 

Age. — From the records of about seventy cases of inflammatory disease 
of the digestive mucous membrane which I have preserved, it appears that 
gastritis is rare over the age of six months. On the other hand, it is not 
uncommon in infants under the age of three months who are deprived of 



SYMPTOMS. 597 

the breast-milk. I have met it chiefly in foundliDgs fed with the bottle, 
and having at the same time entero-colitis and often also stomatitis and 
oesophagitis. In these cases there is sometimes continuous or almost con- 
tinuous injection and thickening of the mucous membrane, from the lips 
to near the pyloric orifice of the stomach, and even beyond this orifice in 
the intestines. The following is an example of gastritis as it frequently 
occurs in foundling institutions : 

Case.— R. W., female, two weeks old, was admitted into the New York 
Infant Asylum, August 24th, 1865, am^mic and somewhat emaciated. It 
was in part wet-nursed, and in part bottle-fed. The emaciation increased, 
and nearly the entire buccal cavity became covered with the confervoid 
growth of thrush. On September 4th, diarrhoea commenced. Borax was 
used for the mouth, and alkalies and astringents to check the diarrhoea, 
but without material improvement. 

The following was the record for September 7th : " Cries almost con- 
stantly, with feeble or whining voice ; still has thrush ; nurses and does 
not vomit ; stools five or six daily, and green ; pulse 136, feeble." Death 
occurred September 8th. 

Autopsy September 9th. — Mouth and fauces not examined ; mucous mem- 
brane of oesophagus vascular in its whole extent, with slight thickening, 
but without ulceration ; mucous membrane of stomach injected like that 
of the oesophagus, and somewhat thickened, except in its pyloric extremity, 
where the appearance was natural, or nearly so ; the color in the central 
part of the inflamed gastric membrane was deep-red ; no thrush was noticed, 
except on the buccal surface during life ; along the great curvature of the 
stomach were white flakes, resembling those of thrush, but which were 
found by the microscope to consist mainly of oil-globules and epithelial 
cells, without the cryptogamic formation ; mucous membrane of small in- 
testines healthy in their w^hoie extent, except slightly increased vascularity 
in a few places in the ileum ; mucous membrane of colon much injected 
throughout, except near the ileo-coecal valve, where the vascularity was 
slight ; in the transverse and descending colon, the redness was pretty 
uniform; and the membrane was thickened, but not ulcerated; solitary 
glands and Peyer's patches somewhat elevated. 

The observations of Valleix show how fz-equently gastritis is associated 
with severe attacks of thrush. In twenty-three of his cases of the latter 
disease, in which the condition of the stomach was noted after death, this 
organ presented inflammatory lesions in seventeen, and in three others 
appearances which may or may not have been due to inflammation. 

Symptoms. — A difficulty exists in isolating and defining the symptoms 
of gastritis, from the fact that it commonly coexists with other inflamma- 
tion of the digestive tube. Though we may never be able to diagnosticate 
this affection as certainly as we can croup or pneumonitis, still, there are 
symptoms which arise directly from the gastritis, and with care we may 
be able to distinguish them from those symptoms which are due to other 
pathological states. 

If gastritis is acute, pain is present. In the above case from Billard, 



598 GASTRITIS. 

as well as in a case observed by myself and related under the head of 
gelatinous softening, there were frequent cries, and the countenance indi- 
cated much suffering, until the stage of collapse. If there is less intensity 
of inflammation, and the disease is more protracted, as is ordinarily the 
case, the pain is not so severe, and it may be so slight as not to attract 
attention. Sometimes there is tenderness, so that pressure upon the epi- 
gastric region is badly tolerated. Vomiting is regarded as one of the 
most constant symptoms. The infant after nursing seems in distress till 
the milk is returned, but it nurses with avidity in consequence of the 
thirst, if it is not too exhausted or feeble. The dejections may be quite 
regular throughout the disease, as in the case from Billard. There is ordi- 
narily, however, diarrhoea from the presence of entero-colitis. The pulse 
is sometimes accelerated, and sometimes nearly natural. The emaciation 
in gastritis is rapid, since not only the milk is in great measure vomited, 
but the digestive function, so far as the stomach is concerned, is seriously 
impaired. The features become wrinkled and senile, the eyes hollow, the 
limbs attenuated, and the cranial bones uneven. Death occurs from ex- 
haustion. 

Anatomical Characters. — Simple gastritis may affect the entire 
mucous surface of the stomach, or be limited to a certain part. The part 
which is most likely to escape is that towards the pyloric orifice. This 
portion of the organ is sometimes found in nearly or quite the normal 
state, while the cardiac half or two-thirds is inflamed. The vascularity 
of the diseased surface is not uniform. In one place there is simple 
arborescence ; in another intense continuous redness, and between these 
two extremes are different grades of vascularity. The mucous membrane 
is somewhat thickened, softened, and the secretion of mucus increased. 
Extravasation of blood is not infrequent under the mucous membrane, 
usually in points, and the mucus may be mixed with more or less blood. 
Small shreds or portions of coagulated milk are often found with the 
mucus attached to the gastric surface. I have observed, though rarely, 
small superficial ulcers at the point where the inflammation had been most 
intense. 

Diagnosis. — In protracted cases, when entero-colitis is present, it is 
difficult to make a positive diagnosis. Our opinion must then be little 
more than a plausible conjecture. In the acute attacks we can diagnosti- 
cate the gastritis with more certainty. If a young infant affected with 
thrush is seized with pain, and it vomits often ; if emaciation is rapid, and 
there is no diarrhoea, or diarrhoea not sufficient to account for the prostra- 
tion ; if the buccal mucous membrane, dotted with the points of thrush, 
presents a dry appearance and the deep-red color of severe stomatitis, 
there can be little doubt of the presence of gastritis. The diagnosis is 
rendered more certain by signs of tenderness when pressure is made upon 
the epigastric region. 



FOLLICULAR GASTRITIS. 599 

Prognosis. — Like other inflammations, gastritis is pi'obably sometimes 
so mild that it does not materially increase the suffering or danger of the 
child. This mild form of the disease under favorable circumstances soon 
subsides. In other cases, by the continuance or increase of the cause, the 
inflammatory process becomes more severe and extensive, resulting even 
in disintegration of the mucous membrane. Those cases are especially 
severe and likely to terminate fatally, which are protracted and accom- 
panied by severe thrush, Avith a desiccated appearance of the mouth, or 
with entero-colitis. Pain, vomiting, and rapid emaciation in such chil- 
dren indicate the speedy approach of death. Improvement in the stoma- 
titis or entero-colitis is a favorable indication, but these inflammations 
may improve without corresponding improvement in the gastritis. 

Treatment. — All food or drinks, except those of a bland and unirri- 
tating nature, should be forbidden. If practicable, the young infant 
should take no nutriment except the mother's milk or that of a wet-nurse. 
As there is an excess of acid in inflammation of the mucous coat of the 
digestive tube, lime-water may be advantageously given in combination 
with the breast-milk. Opium is required to relieve the pain and quiet the 
action of the stomach. The camphorated tincture of opium, in doses of 
four or five drops to a child a month old, or the syrup of poppy, tincture 
of opium, or liquor opii compositus, in proportionate doses, may be admin- 
istered. If there is thirst, a little gum-water should be given frequently. 
If there is much emaciation and the vital powers are failing, it will be 
necessary to resort to the use of stimulants. Stimulating enemata are 
preferable to stimulants given by the mouth. Much benefit may be an- 
ticipated from local measures. Irritation should be produced upon the 
epigastrium by mustard or other means, followed by fomentations. It is 
rarely, perhaps never, proper to use leeches, if the patient be a young 
infant. Death occurs from exhaustion, and it is, therefore, important 
that the vital powers should not be reduced. If the child is weaned, the 
diet at first should be restricted to arrowroot, rice-water, barley-water, or 
similar bland substances. In advanced stages of gastritis, animal broths 
and jellies may be required. 

Follicular Gastritis — Diphtheritic Gastritis. 

The pathological character of follicular gastritis is similar to that of fol- 
licular stomatitis. It is an inflammation affecting the gastric follicles and 
ending in their ulceration. It is not a frequent disease ; it occurs in young 
infants. Billard observed fifteen cases. The symptoms in these patients 
were similar to those in simple gastritis of a severe form. The emaciation 
and prostration were rapid, and death occurred early. We can only diag- 
nosticate the gastritis without determining its follicular character. How 
many recover it is impossible to ascertain, but the disease is apt to be fatal 



600 SOFTENING. 

on account of the intensity of the inflammation, not only of the follicles 
but of the intervening mucous membrane. The treatment is that of gas- 
tritis. 

Diphtheritic gastritis is infrequent. It occasionally occurs during 
epidemics of diphtheria. Allusion is elsewhere made to a case treated in 
the Nursery and Child's Hospital of this city, in December, 1859. The 
patient, eighteen months old, previously had had protracted entero-colitis, 
and died exhausted after a brief attack of diphtheria. There were lesions 
referable to the entero-colitis, and the body was much emaciated. The 
diphtheritic exudation was found covering the fauces, epiglottis, glottis, to 
the rima glottidis, the entire oesophagus, and almost the entire stomach. 
The mucous surface underneath was injected ; that of the oesophagus and 
stomach especially was very vascular, softened and thickened, and the 
submucous connective tissue was infiltrated. 

The pseudo-membrane, taken from the epiglottis and examined under 
the microscope, presented an amorphous appearance : no cells were noticed 
in it, and fibrillation was not distinct ; that from the stffmach was found 
to consist almost entirely of cells, the plastic corpuscles of some writers, 
the pyoid of others. The digestive process, so far as the stomach was con- 
cerned, had evidently been almost if not entirely suspended, and hence in 
part the sudden prostration. Diphtheritic gastritis probably does not occur 
without general infection of the system with the diphtheritic virus. 

Post-mortem Digestion, Softening. 

It is now many years since the attention of the profession was directed 
to disorganization of the coats of the stomach, which is sometimes observed 
at post-mortem examinations. John Hunter first ascertained that the 
gastric juice begins to have a solvent effect on the tissues of the stomach 
soon after death. Though Hunter ei'red, when he stated that the coats of 
the stomach are more or less digested in all or nearly all cases, it is cer- 
tain that post-mortem digestion does take place in many cadavers, so that 
a few hours after death the gastric mucous membrane is destroyed to a 
greater or less extent, and occasionally the stomach is perforated or is even 
severed from its connection with the oesophagus. I have seen several ex- 
amples of this post-mortem perforation in infants. 

Some of the cases of supposed pathological softening of the stomach 
reported by the older observers, seem to have been such as I have described, 
namely, cadaveric. Yet there are two other kinds of softening occurring 
in children, which are strictly pathological, the one designated white, the 
other, by Cruveilhier, gelatinous. 

White softening of the gastro-intestinal mucous membrane results from 
deficient alimentation. It has been observed only in anaemic and ill-nour- 
ished children. The mucous membrane in such loses its firmness, and is 



ITS NATURE. 601 

easily separated from the subjacent tissue. This disorganization has no 
connection with any inflammatory process. It is simply a disintegration 
of the mucous membrane in consequence of the low vitality of the patient, 
whether or not there are co-operating causes. I believe that, in a large 
proportion of infants whose systems have been reduced and blood impov- 
erished for a considerable time, the gastro-intestinal mucous membrane 
will be found after death less firm and resisting than in those who have 
been habitually robust. Probably acids which collect in the primse vias, 
have much to do with this softening. 

A vague opinion exists in the minds of most physicians as to the nature 
and even appearance of the so-called gelatinous softening of the stomach, 
and the following observations will be cited in order to give a clearer idea 
of it. 

Billard has recorded two cases with his usual minuteness, and adds: 
" What inference shall be drawn from the preceding fixcts and considera- 
tions? None other than that the gelatinous softening of the stomach con- 
sists in a disorganization of the mucous membrane of this viscus, caused 
by an acute or chronic phlegmasia ; that this disorganization is charac- 
terized by an accumulation of serum in the walls of this organ ; the intu- 
mescence and gelatinous consistence of the mucous membrane in a part 
usually circumscribed, situated more frequently in the greater curvature, 
and about which the membrane exhibits more or less evident traces of an 
acute or chronic phlegmasia. . . . The softening now under consideration 
must not be confounded with another kind of softening" (white) "which 
does not usually succeed an acute phlegmasia." 

Billard believes that, while gelatinous softening results from inflamma- 
tion of the mucous membrane, its proximate cause is an afilux of serum to 
the part in which the disorganization occurs. In one of the two cases which 
he reports, he thinks that the inflammation was acute, but in the other 
chronic, and, therefore, presenting less vascularity. 

West, in speaking of gelatinous softening, says : "Softening of the stom- 
ach varies in degree from a slight diminution in the consistence of the mu- 
cous membrane, to a state of complete difiiueuce of all the tissues of the 
organ. . . . When the change is not far advanced, the exterior of the 
stomach presents a perfectly natural appearance, but on laying it open a 
colorless or slightly brownish tenacious mucus, like the mucilage of quince- 
seeds, is found closely adhering to its interior, over a more or less consider- 
able space at the great end of this organ." 

Cruveilhier says : " This softening often proceeds from the interior to- 
wards the exterior. There is at the beginning simple separation of the 
fibres by a gelatinous mucus, and in consequence the parietes are thick- 
ened and semi-transparent. ... If the transformation be complete, the 
disorganized portions are removed layer after layer, those which remain 
becoming gradually thinner. The peritoneum alone resists for some time, 



602 SOFTENIXG. 

but at length it is attacked, worn, aud gives way, and perforation of the 
stomach results. The parts thus transformed are colorless, transparent, 
apparently inorganic, completely deprived of vessels, and exhaling an odor 
resembling that of milk." 

Bouchut remarks : " Softening of the mucous membrane of the stomach 
in children at the breast is not a special disease which it is necessary to 
describe by itself. This alteration is always connected with other diseases, 
and is especially with disease of the large intestine, the knowledge of which 
fact has been too long neglected. It is the consequence of the acidity of 
the liquids contained in the digestive tube of young children, liquids which 
are very acid in the disease we have above referred to." 

Dr. Carswell states that there is a pathological softening of the mucous 
membrane of the stomach, and that when it occurs the symptoms may be 
those of gastritis or enteritis. 

Eokitansky says of this form of softening : " If we consider, in addition 
to the above remarks, the uniform localization of the disease, that in none 
of its .stages it presents, either at the point of the softening or in its vicinity, 
hypersemic injection or reddening, and that we are still less able to demon- 
strate upon the inner surface of the stomach or in the tissue of its coats the 
products of inflammation, we are constrained to infer the non-inflamma- 
tory nature of the affection." 

Without extending these extracts, it is seen that eminent authorities not 
only disagree in reference to the cause of gelatinous softening of the stom- 
ach, but that they also differ in their description of its appearance. This 
diversity of opinion is most likely attributable to the fact that the two kinds 
of softening have been confounded. Rokitansky and Bouchut probably 
refer to cases of white softening, which occurs in atonic states of the tissues 
in feeble infants, and, therefore, have concluded that softening of the stom- 
ach is not inflammatory. I believe, from my observations, that the opinion 
of Billard is correct, and that true gelatinous softening is the result of 
gastric inflammation, sometimes chronic, sometimes acute. But I have seen 
appearances which led me to think that the immediate causes of the soften- 
ing continue to operate after death, so that its amount is less at the time of 
death than a few hours subsequently. 

The following case, which was watched by myself with great interest, 
from beginning to end, is an example of inflammatory softening: 

Case. — G. S., male, robust, was born July 10th, 1865. The mother not 
being able to suckle the infant, and the danger of artificial feeding in the 
warm mouths being well understood, a wet-nur.se was procured. About 
the 14th of July, this wet-nurse having insufficieut milk, another was pro- 
cured temporarily, who suckled the infant till July 20th, when a third 
wet-nurse was engaged, whose child, healthy and thriving, was six weeks 
old. Previously to this time the infant appeared well. It had uniformly 
nursed vigorously and seemed satisfied. 

On the 22d of July, thrush, apparently mild, was observed in the mouth, 



CASE. 603 

and a powder, supposed to be borax, and labelled such, was obtained at a 
drug store, to be used as a wash for the mouth. This powder was after- 
ward ascertained to be alum. About five grains were dissolved in as many 
teaspoonfuls of water, and the mouth of the child was swabbed occasion- 
ally W'ith it. A piece of linen, folded so as to resemble the tip of a nursing 
bottle, was occasionally dipped into the solution, and the infant Avas allowed 
to suck it. The use of the alum was commenced about 6 p.m. In the 
first part of the evening the infant slept considerably, and of course did 
not nurse often, but about 8 p.m. it began to be very fretful, and it then 
nursed more frequently. It vomited once between 8 and 10 o'clock p.m. 
In order to quiet the infant, the tip soaked in the solution was often ap- 
plied to the mouth, but there was scarcely any intermission in its crying. 
Through the night it vomited again once or twice, and about the middle 
of the night had one free liquid stool, which was passed with much tenes- 
mus. The countenance of the infant was indicative of suffering, and its 
thighs were repeatedly flexed over the abdomen, as if that were the seat of 
its distress. Paregoric in two-drop doses was several times given through 
the night, and flannel soaked with hot whisky was applied to the ab- 
domen. 

July 23d. In ignorance of the cause of the child's sickness, another wet- 
nurse was obtained early in the morning, and one-sixth of a drop of liq. 
opii compos, was given every hour, with the effect of inducing a little sleep. 
The tongue w^as very red, desiccated, and studded with more numerous 
points of thrush than on the previous day. It now refused to nurse, ap- 
parently from soreness of the tongue. At each attempt of the nurse to in- 
duce it to take the nipple, it rubbed the mouth across the breast, crying 
either from pain or disappointment. The alum w'as not used in the latter 
part of the night of the 22d, but late in the morning of the 23d it w-as re- 
sumed, the mistake of the druggist not being discovered till midday, when 
it was estimated that about five grains had been used. Occasionally a 
little of the solution was placed in the mouth with a spoon so as to be 
swallowed, in the belief that the thrush affected the oesophagus. The in- 
fant continued to suffer much during the day, sleeping at times a few 
minutes. Its strength was evidently failing; its respiration regular; pulse 
about 140; its alvine discharges yellow, of natural consistence and fre- 
quency. 

Evening 23d. Surface hot; is very restless ; pulse 150 to 160 ; tongue 
dry, intensely red, and dotted with points of thrush. Is treated with 
opiates, a little lime-water, and fomentations. 

24th. In the first part of the day, nursed pretty well ; in the latter part, 
could be induced to draw the breast only once or twice. The symptoms 
to-day were the same as yesterday, with the exception of greater emaci- 
ation and prostration ; cranial bones uneven, and features pinched. 

25th. Pulse 140 to 148 ; strength I'apidly failing, but it cries at times 
loudly. The milk of the nur.se, placed in the mouth with a spoon, is often 
held a considerable time before it is swallowed, and deglutition seems dif- 
ficult. Respiration in the first part of the day and previously, natural ; in 
the latter part of the day, accelerated ; dejections natural ; no vomiting ; 
appearance of tongue more natural than yesterday. 

26th. Died to-day in a state of collapse at 12i p.m. The hands were 
cold several hours before death, and the milk given it was regurgitated. 

Aidopsy hventy-huo hour.H after death. — Much emaciation ; no rigor mor- 
tis ; cranial bones uneven ; upper part of the pharynx injected to the ex- 



604 SOFTENING. 

tent of about half an inch; but from this point to the stomach membrane 
healthy; raucous membrane covering the cardiac two-thirds of the stomach 
disintegrated, almost diffluent, and in places detached from the subjacent 
tissue; mucous coat of the pyloric third of the organ nearly healthy ; along 
the edge of the softened portion the mucous membrane was vascular to the 
extent of a few lines; the muscular and serous coats of the stomach under- 
neath the softened portion were easily torn ; the mucous membrane of the 
small intestine presented in places that degree of vascularity known as 
arborescence ; there was no destruction or softening of its mucous mem- 
brane ; the colon was healthy ; the stomach was nearly empty ; the contents 
of the small and large intestines were natural in color and consistence ; the 
other viscera were healthy ; in the left pleural cavity was about au ounce 
of transparent serum, and a less quantity in the right cavity. 

It cannot be doubted that the softening in the above case was pathologi- 
cal. The weather at the time was warm, but the infant was placed on ice, 
and a pan containing ice was kept upon the abdomen. This infant died 
evidently of gastritis, the accompanying inflammation being subordinate, 
and in fact insignificant. At first it was a question with me, whether the 
alum might not have caused the gastritis, so that the case should be prop- 
erly placed in the category of deaths from swallowing corrosive substances. 
In order to determine this point, I administered alum daily to two kittens, 
commencing when they were seven days old. The quantity given to each 
was ten grains daily in two doses for three consecutive days, and on the 
two following days five grains. The only uniform result noticed was an 
increased flow of saliva, which washed some of the alum from their mouths, 
and occasionally slight vomiting. There was not even any apparent in- 
flammation of the buccal membrane from the alum. 

Post-mortem appearances as in the above case, and similar ones are re- 
corded by Valleix and others, in which gelatinous softening coexisted with 
evident lesions of gastritis, render it highly probable, if indeed they do not 
demonstrate, that the softening is a result of the inflammation at the point 
where it occurs. 

In Valleix's twenty-four cases of what he terms fatal muguet, softening 
of the mucous membrane of the stomach was one of the most common 
lesions, and at the same time, which is the point of interest, there were 
signs which showed conclusively the presence of gastric inflammation. 
The common coexistence of the lesions of gastric inflammation, such as 
redness and thickening, with gelatinous softening of the stomach, is cer- 
tainly most reasonably explained on the supposition that the one results 
from the other. 

I am not prepared to accept nor reject the theory of Billard, that the 
immediate cause of the softening is the afflux of serum, nor that of Bou- 
chut, that it is an excess of acid. 

It has been said that M. Baron was able to diagnosticate gelatinous 
softening. The symptoms are those of the severer forms of gastritis. The 



NON-INFLAMMATOEY DTAERHGEA. 605 

vomitiug, great pain, restlessness, sudden and progressive emaciation, and, 
finally, collapse preceding the fatal result, are the symptoms on which the 
diagnosis is based. The treatment should be directed to the gastritis. 
(Amer. Jour, of Med. Sci., January, 1841.) 



CHAPTER VII. 

DIARRHCEA. 

DiAERHCEA is frequent during the whole period of infancy. The French 
writers describe several varieties according to the character of the evacu- 
ations, as acescent, mucous, and serous. M. Rostan even describes fourteen 
distinct kinds. But the tendency of medical science in these modern times 
is to simplify the nomenclature of diseases — to describe under a single 
name those affections which are essentially the same though differing some- 
what in their features. Now, all the forms of diarrhoea in the infant may 
be so grouped as to reduce the number to not more than three or four. 
In this way repetition and prolixity are avoided, as well as an unnecessary 
refinement. 

Non-Inflammatory Diarrhoea. 

The most common and the simplest form of diarrhoea is that enunciated 
in our heading. Though attended often by an anatomical alteration in 
the intestines, the inflammatory character is absent. This disease is de- 
scribed by some writers as simple or spasmodic diarrhoea. Many cases of 
diarrhoea supposed to be non-inflammatory are really cases of entero-coli- 
tis, and very frequently diarrhoea not inflammatory in its commencement 
changes its character and becomes such. This is especially true of such 
diarrhoeal affections as are produced by improper diet. 

Causes. — The causes of non-inflammatory diarrhoea are various. In- 
fluences, which in the adult would have no appreciable effect, increase the 
number of evacuations in the infant. 

A common cause is food of unsuitable quality or quantity. Food that 
does not digest well is apt to stimulate the intestinal follicles to excessive 
secretion and accelerate the peristaltic action of the intestines. In infants 
diarrhoea is sometimes due to too frequent feeding. Many whose stomachs 
are overloaded obtain relief by vomiting, but others do not. The food not 
needed for nutrition serves as an irritant, and produces green and un- 
healthy evacuations. Dr. James Jackson, in his letters to a young physi- 
cian, calls attention to this cause of diarrhoea. 



606 NON-INFLAMMATORY DIARRHCEA. 

The mother's milk or the milk of the ■\vet-iuirse may disagree, either 
from some temporary derangemeut of her system, or continued ill-health, 
or from causes which are not understood. Non-inflammatory diarrhoea in 
the nursling is the immediate result, but inflammation may afterwards 
occur. The milk in these cases frequently contains the elements of colos- 
trum. 

Fright or strong mental impressions will also in some children increase 
the number of evacuations. This cause being transient, the diarrhcea 
soon subsides. 

Another cause is exposure to cold. Children w^io are insufficiently 
clothed in the winter season, who are taken from a heated room into a 
cool one without sufficient precaution, or who lie uncovered at night, are 
very subject to diarrhoeal attacks from the impression of cold on the system. 

The cause of non-inflammatory diarrhoea may exist in the child itself. 
In some children the evolution of the teeth is attended by a relaxed state 
of the bowels, which ceases when the gum is pierced. Worms in the intes- 
tines may also operate as a cause. Diarrhoea is occasionally salutary within 
certain limits, and of course it is not strictly correct to call it a disease 
when it is a means of relief. If occurring from an excess of food or from 
dentition, it may prevent convulsive seizures. 

ISymptoms. — Non-inflammatory diarrhoea may come on suddenly ; at 
other times there are precursory symptoms continuing for some days. 
Whether or not there are antecedent symptoms depends chiefly on the 
cause. If diarrhoea occur from fright, or from cold, or from improper 
aliment, it commonly occurs immediately. If from painful dentition, 
there are previous symptoms referable to the eruption of the teeth. 

The prodromic symptoms are restlessness and disturbed sleep ; sometimes 
the physiognomy indicates transient abdominal pains. Indigestion, char- 
acterized by regurgitation, nausea, or even vomiting, is an occasional pre- 
monitory condition. Finally diarrhoea commences. The evacuations differ 
much in color and consistence in different cases, and perhaps at different 
periods in the same case. In infants they are apt to be green. This color, 
which is a source of anxiety to the inexperienced, and especially to the 
parents, is often produced by trivial causes. Slight indigestion will pro- 
duce it. So will excess of food, even the most bland and uuirritating. 
Occasionally the stools consist in part of undigested portions of food, 
especially the casein. In children advanced beyond the period of first 
dentition the evacuations do not differ materially in appearance from 
those occurring in the adult. The stools are usually passed easily, but 
there is sometimes in infants more or less tenesmus, if they are acid or 
in any way irritating. Occasionally there is a sensation of fulness in the 
abdomen. 

In the form of diarrhcea which has been designated acescent, not only 
is there an acid odor and reaction of the matter vomited, but also of the 



ANATOMICAL CHARACTERS. 607 

stools. At night, since less nutriment is taken, and the patient is more 
quiet, the evacuations in non-iufiammatory diarrhoea are less frequent than 
in the daytime. If the complaint is slight, there is little desire for drink, 
but if the stools are frequent and thin, especially if they approach the 
serous character, thirst is often intense ; the appetite varies ; the tongue is 
moist, and covered with a light fur; there is often more or less meteorism, 
but no abdominal tenderness. 

The face in this disease is pale. In a few days if the evacuations con- 
tinue, there is evident loss of weight and flesh. The rotundity of the limbs 
is gradually lost, and the tissues become soft and flabby. But in most cases, 
when the malady had reached this stage, its original character is lost, and 
it has become inflammatory. 

There is no constant fever in true non-inflammatory dian-hoea. Some- 
times the pulse is accelerated in the latter part of the day, but usually only 
for a short time. 

Certain epiphenomeua, as Barrier terms them, occur at times in non-in- 
flammatory as well as in inflammatory diarrhoea, for example a sympa- 
thetic cough, or, which is more serious, cerebral complications. Convul- 
sions or stupor, indicating the supervention of spurious hydrocephalus, may 
occur in either form of diarrhoea. This disease is described elsewhere. 

Anatomical Characters. — The structural changes observed in the 
intestines in those who die of non-inflammatory diarrhoea have been well 
described by Billard. " I have seen," says he, " isolated follicles, and 
follicular plexuses of the intestinal tube, in considerable numbers, and de- 
veloped without being inflamed, in twelve infants. There were three aged 
from eight days to three weeks ; two aged two months ; the remaining seven 
were from nine months to one year. The follicles appear at the commence- 
ment of dentition. Ten of these children were affected with diarrhoea of 
liquid, white, mucous matters. This is really the serous diarrhoea of au- 
thors ; and every symptom leads to the belief that there is a direct relation 
between the development of these follicles and the augmentation of their 
secretion." . . . " I do not consider this morbid development of the mu- 
ciparous follicles as a true inflammation. Nevertheless, this state of ex- 
citability which causes the augmentation of their secretion is, as it were, 
an intermediate stage between the normal state and the state of inflamma- 
tion." Barrier's views also coincide, in the main, with those of Billard. 

One of the most common lesions observed in the intestines, in those who 
have died with non-inflammatory diarrhoea, is, as these authors remark, 
turgescence of the intestinal glands. In a large proportion of cases these 
glands will be found more distinct than in the healthy state. 

The solitary follicles of the large intestines, especially, are, in most 
cases, elevated, and their central depression distinct ; the patches of Peyer 
are also prominent. 



608 NON-INFLAMMATORY DIARRHCEA. 

The following is an example of non-inflaniuiatory diarrluca in a young 
infant : 

On the 7th of July, 18G5, a foundling, one month old, died at the Infant 
Asylum. It was much emaciated, with eyes sunken and features pinched, 
at the time of its death. It was wet-nursed towards the close of its life, 
but the nurse's milk was insufficient. It did not vomit ; did not have any 
marked acceleration of pulse (128 per minute), and its evacuations were 
about four daily, and thin. The stomach and intestines were pale through- 
out. The solitary glands, particularly those in the colon, and the patches 
of Peyer, were tumefied so as to be visible, and somewhat raised above 
the surrounding surface. There was probably slight thickening of the 
mucous membrane, and tumefaction of the muciparous follicles, but these 
changes were not clearly ascertained. 

Diagnosis. — The only disease with which there is liability of confound- 
ing non-inflammatory diarrhcea is enteritis or entcro-colitis. From these 
it may be diagnosticated by the absence of continued fever and of abdomi- 
nal tenderness. Sometimes, indeed, it is difficult to say whether the case 
is non-inflammatory or whether there exists a moderate degree of in- 
fiaramation, though practically the determination of this j^oiut is not im- 
portant. 

Prognosis. — In a large proportion of cases, non-inflammatory diarrhoea 
is not dangerous. With the adoption of suitable measures to remove the 
cause, and the use of medicines to control the discharges, the patient re- 
covers. The remark already made may be repeated here, that occasionally 
diarrhoea is salutary within certain limits, as when there is a foreign sub- 
stance in the intestines, either irritating mechanically or by its chemical 
properties, and which the diarrhoea serves to remove. 

The danger, in non-inflammatory diarrhoea, arises from complications, 
as spurious hydrocephalus, or from the emaciation and exhaustion. There 
may also be danger of its eventuating in inflammation, which is always 
serious. Whether or not the diarrhoea is in itself injurious to the child, 
and a source of danger, may be determined by observing whether or not 
there is emaciation. 

If the rotundity of the figure and firmness of the tissues are preserved, 
showing that alimentation is still sufficient, and no complication arises, the 
diarrhoea is not as a rule injurious. In infants that over-nurse and do not 
vomit the surplus milk, the evacuations are sometimes green and frequent, 
and yet fulness of figure is preserved, and the development of the body 
proceeds as usual. The same state is sometimes observed in the diarrhoea 
accomj^anying dentition. In these instances a moderately relaxed state of 
the bowels is not injurious. On the other hand, diarrhoea attended by 
emaciation or softness or flabbiness of the flesh requires immediate treat- 
ment. Many lives are lost by the neglect of such patients till they are so 
reduced that they can no longer derive any material benefit from reme- 



TREATMENT. 609 

dial measures. This fatal neglect is common during the process of den- 
tition. 

. Treatment. — It is necessary, in order to treat successfully diarrhoea in 
infancy and childhood, to ascertain the cause, and, so far as possible, to 
remove it. It is not till the cause ceases to operate, that we can expect a 
satisfactory result from medication. The disease may be temporarily re- 
lieved by medicine, but it usually returns at once when treatment is omitted, 
unless the patient is removed from the influence of the agencies which pro- 
duce it. These remarks are especially applicable to the diarrhoea of in- 
fants. With them very generally, when affected with this complaint, there 
is some fault as regards the quantity or quality of food. Attention to this 
matter will show the need of a change of wet-nurse, or, if the infant be 
spoon-fed, a change in the character of its food or the mode of preparation 
or even in the quantity given. In many cases, by change in the diet, and 
the adoption of hygienic measures, the complaint ceases, so as to require 
no medication. If medicines are needed, and, the symptoms are not urgent, 
it is occasionally advantageous to commence treatment by the use of some 
of the milder purgatives in small doses. In the infant, in whom the de- 
jections are so generally acid, an alkaline laxative, or a laxative conjoined 
with an alkali, often has a good effect as preliminary treatment. Haifa 
teaspoonful to one teaspoonful of castor oil, or a proportionate dose of cal- 
cined magnesia, removes any acid or irritating substance from the intes- 
tines, and is followed by a diminution in the number of stools. The im- 
provement, however, without subsequent treatment, is usually only for a 
day or two. The use of a purgative should, therefore, be considered as 
preliminary to other measures. In this city a purgative dose of castor oil 
is often given as a domestic remedy in infantile diarrhoea, the beneficial 
effect from it having popularized its use for this purpose. Trousseau usually 
gave Rochelle salts, but this medicine is too severe and dangerous for the 
treatment of infantile diarrhoea, especially in the warm months. 

If there has been previous constipation, and the diarrhoea has just com- 
menced, a purgative is obviously indicated. West says : " Provided there 
be neither much pain nor much tenesmus, and the evacuations, though 
watery, are f^cal, and contain little mucus and no blood, very small doses 
of tlie sulphate of magnesia and tincture of rhubarb have seemed to me 
more useful than any other remedy : 

R. Magnpsite sulpliatis, gj. 
Tinct. rhoi, jj. 
Syr. zingiberi.s, gj. 
, AquiB carui, 3ix. Misce. 

3j tei* die for childroii oin' yi'ar old ; 

and I seldom iiiil to observe from it a speedy (liminulioii in the 1V( (picncy 
of the action of the bowels, antl a rrlurn oi' the natural character of the 
evacuations." 



610 XON-INFLAMMATORY DIAERHCEA. 

In diarrhoea of infants, due to indigestion, and attended by acidity, the 
following prescription is sometimes useful. By improving digestion and 
correcting acidity, it has a beneficial effect on the diarrhoea. The cases 
are, however, in my experience exceptional in which this is the proper 
remedy. 

K. Pulv. ipecacuanhse, gr. ss. 
Pulv. rhei, gr. ij. 
Soda? bicarb., gr. xij. Misce. 
Divide in chart. No. xij. One powder every four to six hours to an infant one 
year old. 

The effect of laxative medicines, employed for the purpose of correcting 
the functions of the gastro-intestinal surface, is uncertain. If there is no 
improvement from their use within two or three days, they should be 
omitted. We must rely on astringents, opiates, and, in infants, also on 
alkalies. If the symptoms are urgent, if the evacuations are frequent 
and exhaustive, these agents should be employed from the first. Much 
harm is often done, and precious time lost, by prescribing laxative mix- 
tures when opiates and astringents are required. I have known them to 
aggravate the complaint, when, by change of measures, there was imme- 
diate improvement. The majority of cases of non-inflammatory diarrhoea, 
at the period when the physician is called, are best treated by the use of 
astringents and opiates exclusively, proper directions at the same time 
being given in reference to the diet and hygienic management. 

In the diarrhoea of infants the compound powder of chalk and opium 
is an excellent medicine, containing, as it does, an astringent with the 
opiate and alkali. It may be given in doses of three grains, to a child 
one year old, every three hours. I ordinarily employ it with double its 
quantity of subnitrate of bismuth, and know no better remedy for ordi- 
nary cases. The following is also an old but useful prescription in the 
simple diarrhoea of infants : 

li. Tinct. opii camphorat., 
Tinct. catechu, aa ^ij. 
Mistur. cretsB, 5J. Misce. 
Dose, one teaspoonful every two to four hours to a child one year old, or, better, 
the laudanum, bismuth, and chalk mixture, recommended in our remarks upon the 
treatment of indigestion. 

Kino, kameria, or logwood may be used in place of the astringents 
mentioned above. If the diarrhoea is due to the feeble digestive powers 
of the patient, and its food is therefore irritating, powdei's of pepsin and 
subnitrate of bismuth should be employed. 

In the treatment of non-inflammatory diarrhoea occurring in infancy, it 
is rarely necessary to use the mineral astringents, as acetate of lead or 
nitrate of silver. If the patient is not relieved by opiates, alkalies, and 



INTESTINAL INFLAMMATION OF INFANCY. 611 

the vegetable astringents, and by proper regimen, in all probability there 
is inflammation of the intestinal mucous membrane. In patients over 
the age of two or three years simple diarrhoea approaches in character 
that of the adult, and the treatment appropriate for the adult is proper in 
these cases, allowance being made for the difference of age. In infants, 
in- whom this disease, if protracted, is verj^ liable to eventuate in spurious 
hydrocephalus, stimulants are often required at an early period, on ac- 
count of the prostration and feeble power of endurance. 



CHAPTER VIIL 

INTESTINAL INFLAMMATION OF INFANCY. 

It is customary with writers to treat of inflammation of the small and 
large intestines in infancy as a single disease, for the following reasons : 
First, the symptoms of colitis, at this period of life, do not ordinarily 
differ, in any marked degree, from those of enteritis. The tormina, tenes- 
mus, and abdominal tenderness, which characterize colitis in childhood 
and adult life, are ordinarily lacking, or are not appreciable by the ob- 
server ; and the rauco-sanguineous evacuations are oftener absent than 
present. On account of this absence of symptoms, Bouchut says : " Dys- 
entery is a very rare disease amongst young children. Its existence 
might even be denied, if it had not been observed at the period of some 
severe epidemics of dysentery." If Bouchut refers, by the term dysen- 
tery, to the ordinary phenomena of that disease, his remark is correct ; 
but, as regards the lesions, it is erroneous, for colitis is not so rare in 
infancy as his remark implies. Billard, after analyzing eighty cases of 
intestinal inflammation in infants, says: "From this calculation, it is 
evidently very difficult to make a correct diagnosis of inflammation of 
the intestinal tube in sucking infants, yet it would seem as if the proper 
signs of enteritis or ileitis were the rapid tympanitis of the abdomen, the 
diarrhoea, accomjjanied with vomiting; while in colitis, diarrhoea alone, 
without tympanitis, is the most frequent." And again : " In consequence 
of the impossibility we have found to exist of tracing wdth exactitude the 
series of symptoms proper to inflammation of the different portions of the 
digestive tube, we shall content ourselves with presenting an analytical 
sketch of the causes, symptoms, and ordinary course of inflammation of 
the mucous membrane of the intestines in general." 

The frequent absence of any pathognomonic symptom or sign, by which 
to determine the exact seat of intestinal inflammation in the infant, is ad- 
mitted by recent observers as well as Billard. 



612 INTESTINAL INFLAMMATION OF INFANCY. 

The second reason why intestinal inflammation in the infant is described 
as a single disease is, that enteritis and colitis are in the majority of cases 
coexistent. This will be seen when we come to speak of the anatomical 
characters. 

I have hesitated in selecting a terra for this inflammation. The ex- 
pression inflammatory diarrhoea, used by West, is objectionable, because 
it designates a disease by a symptom when there are well-marked lesions. 
To the expression entero-colitis, employed by Bouchut, Meigs, and others, 
there is this objection, that sometimes the disease is only enteritis, and some- 
times colitis ; whereas entero-colitis would imply the presence of both in- 
flammation of the small and the large intestines. Barrier uses the ex- 
pression gastro-intestinal inflammation, but in a large proportion of cases 
gastric inflammation is absent. I have treated of gastritis as an inde- 
pendent aflTection, and it seems proper to exclude it from our description of 
the intestinal disease, except as a complication. 

Although I prefer the term intestinal inflammation, I shall use, in de- 
scribing the disease, the expressions inflammatory diarrhoea and entero- 
colitis as synonymous, in order to avoid too frequent repetition of words. 

Intestinal inflammation is one of the most common and fatal of infantile 
maladies. It is the great summer epidemic of the cities, in this country. 
Unfortunately for a correct understanding of its prevalence and mortality 
in this city, and perhaps elsewhere, it is very generally in the summer 
months when obstinate, and especially when fatal, called cholera in- 
fantum, although, in its symptoms and nature, it is very different from that 
disease. 

Intestinal inflammation is often a protracted complaint, having ordi- 
narily a mild commencement, while the true cholera infantum begins 
abruptly, is characterized by violent symptoms, and rapid and extreme 
exhaustion. 

The 1500 Altai cases of so-called cholera infantum, reported every sum- 
mer in tliis city, are, with now and then an exception, cases of inflamma- 
tion, generally protracted. In like manner, the excess of reported cases 
of infantile marasmus, in the second half of the year, over those reported 
in the first half, should be added to the statistics of intestinal inflamma- 
tion. This excess, which is noticed every year in the mortuary tables of 
this city, is due mainly to the death of those wasted infants who have 
lingered with entero-colitis from the summer months. Their marasmus is 
simply a result of the protracted inflammation. 

Causes. — Inflammatory disease of the intestines in infancy, I have said, 
is chiefly a summer malady — at least, in the cities. Occasionally it is 
observed in the winter, and it is then, when not due to error of diet, pro- 
duced by exposure to cold. Infants who are taken from warm to cold 
rooms, or into the open air, by heedless nurses, or who sleep uncovered at 



CAUSES, 613 

night, are especially liable to this disease. Entero-eolitis produced by this 
cause occurs both in the country and city. 

In these cases the inflammatory process may not commence suddenly. 
There is often a premonitory stage of simple diarrhoea, the first effect of the 
impression of cold. Indeed, in a very large proportion of cases, whatever 
the cause, non-inflammatory precedes inflammatory diarrhoea. 

The influence of the summer season in the production of intestinal in- 
flammation is forcibly shown by the death statistics of this city. Thus, 
for the five years ending with 1863, there were 6379 deaths reported from 
cholera infantum, and of these all but 166 occurred in the months from 
June to October inclusive. The deaths reported for the same years from 
diarrhoea, dysentery, and inflammation of the bowels, were 5914, of which 
3919 occurred in the mouths from June to October. Of the 5914, the 
number under the age of five years was 3257. 

Those familiar with the diseases of this city, and especially with the 
autopsies of infants, will agree that four-fifths of the above cases which 
were reported as cholera infantum or diarrhoea were cases of intestinal 
inflammation. There is no one disease, except consumption, so prevalent 
and fatal in this city as infantile entero-eolitis during the period of its 
epidemic occurrence in the summer months. 

The epidemic commences about the middle of May. From this time 
there is a gradual increase in the number affected, till the months of July 
and August, when the disease attains its maximum prevalence and 
mortality. During the months of September and October, the number 
of seizures and of deaths gradually abates till the epidemic character is 
lost. It is thus seen that the prevalence of intestinal inflammation of in- 
fancy in the city bears a close relation to the degree of summer heat. 
That the high temperature of summer is not in itself sufficient to produce 
entero-eolitis is, however, obvious. In elevated localities in the country 
there may be intense and long-continued heat, and yet in such places 
intestinal inflammation of infants is not common. It is no doubt the 
noxious inhalations from various sources with which the atmosphere is 
loaded, as a consequence of the heat, which render the disease so prevalent 
in certain localities in the summer months. The exact character of these 
exhalations or vapors is not fully known, but the followiug facts are clearly 
established by many observations. 

Entero-eolitis prevails most on low grounds near the seashore. Thus, it 
is common in many parts of Long Island, on Staten Island, and on the 
flats of Westchester County. Experienced and observing physicians of 
this city do not send infants affected in the summer months with entero- 
colitis to these localities, but to the high grounds west of the Hudson, and 
to the hilly parts of New Jersey, where there is comparative immunity 
from the disease, and recovery is more certain and speedy. 

But the state of atmosphere which is most favorable for the develop- 



G14 INTESTINAL INFLAMMATION OF INFANCY. 

meut of entero-colitis is found ouly iu the cities. The filthy streets con- 
taining more or less decaying animal and vegetable matter, the crowded 
and unclean tenement houses, the neglected privies, the slaughter-houses, 
pig-pens, bone-boiling establishments, and the like, are so many sources 
of the most deleterious effluvia, which, inspired by the infant, produce 
diarrhoea and intestinal inflammation. Those squares of the city where 
sanitary regulations are most neglected are the very ones where the mor- 
tality from this cause is largest. 

In the year 1864 the Citizens' Association of the City of New York 
effected a complete and thorough sanitary inspection of New York island, 
and it was interesting as well as painful to note the facts observed by the 
inspectoi's in reference to the prevalence of the so-called cholera infantum 
(chiefly entero-colitis) along the streets and in the alleys where the causes 
of insalubrity were most abundant. 

Thus, one inspector says, of this disease, it " has probably consigned 
many more to the grave during the past summer than all other diseases 
in my inspection district. In every case examined, I have found it as- 
sociated with some well-marked source of insalubrity. Vegetable and 
animal decomposition has been the most prominent cause." AuoLlier in- 
spector says of the same disease : " It was found between the - — — and 
avenues, where the street, at every visit, was found in an indescrib- 
ably filthy state, in consequence of deposits of garbage and slops. This 
was particularly noticed in front of the premises where cholera infantum 
had occurred." Such was the uniform testimony of all the inspectors. 
In the tenement houses and in jwrtions of the city occupied by the poor, 
where the sources of insalubrity are most numerous, I believe, from 
personal observation, that a majority of the infants are more or less 
afl^ected with diarrhoea, often of an inflammatory character, during the 
mouths of July, August, and September. In the more salubrious localities 
of the city, there is less of this disease, but even here the liability to it is 
great, on account of the proximity of so many sources of impure air. 

But there is another and an important element in the causation of in- 
testinal inflammation in the infant. I refer to the diet. Many an infant 
that now falls a victim would escape the disease, but for some fault in the 
character of its food. Those infants in the city who are bottle-fed from 
birth rarely go through the summer without being affected with diarrhoea, 
and a majority of such, if under the age of six months when the warm 
weather commences, are saved from dangerous if not fatal inflammation 
only by removal to the pure air of the country. 

In the families of the poor the food which is given as a substitute for 
the mother's milk is very apt to disagree with the feeble digestive powers 
of tlie infant. The swill milk, about which so much has been said and 
Avritten, is in common use in this city among these people, or has been till 
recently. This milk, in the proportion of its ingredients, and sometimes 



CAUSES. 615 

even in its chemical character, is very different from the milk of healthy 
and well-fed cows of the country. Infants to whom this milk and other 
improper articles of diet are given are the first to suffer with diarrhoea as 
warm weather commences, and finally with entero-colitis. 

It is seen that the causes of intestinal inflammation of infancy as it 
prevails in the cities during the summer are mainly twofold, atmospheric 
and dietetic, — an insalubrious state of the air which the infant breathes, 
and unsuitable food. Among the poor of the cities, both these causes 
conspire to produce the diarrhoeal maladies. It is easy, then, to see why 
there is so much intestinal disease and so great mortality among the infants 
of the city poor. Moreover, on account of their feeble powers of resist- 
ance and endurance they are especially liable to be affected by morbific 
agencies. 

It is a common belief in the profession that dentition is one of the chief 
causes of diarrhoea in the infant, whether inflammatory or non-inflam- 
matory. 

There is, indeed, great liability to this disease during the period of den- 
tal evolution. The following statistics, which were mostly collected during 
my term of service in one of the city dispensaries, and which comprise all 
the cases of diarrhoea under the age of about five years which were brought 
into that institution for treatment during the summer months of my at- 
tendance, show the preponderance of cases in the time of teething. Most 
of these cases were apparently inflammatory. . 

stage of dentition. Number of cases. 

No teeth, 47 

Cutting incisors, ......... 106 

" anterior molars, ....... 41 

" canines, .40 

" last molars, 20 

Having all the teeth, 28 

Total, 282 

It is seen that although a large majority of the above cases occurred 
during dental evolution, yet in a certain proportion, about one in four, 
teething could not operate as a cause. My own opinion is that dentition 
is an occasional cause of simple diarrhoea though a subordinate one, but 
evidence is wanting that it is sufiicient of itself to produce inflammation. 
The diarrhoea of dentition is probably non-inflammatory, terminating in 
inflammation, if such a result follow by the co-operation of other and dis- 
tinct causes. This subject is treated of in our remarks relative to dentition. 

An important predisposing cause of intestinal inflammation in infants 
is the rapid development of the intestinal crypts and follicles. This de- 
velopment, which increases the liability to organic diseases of the intestines, 
is coincident with dentition. Another important cause remiiius to be 



616 INTESTINAL INFLAMMATION OF INFANCY. 

noticed, namely, weaning. Weaning is a subject to which less attention 
is given than its importance demands. The summer succeeding the change 
of diet is always in the city a time of great danger to the infant from 
diarrhoea! affections. Mothers uniformly speak with dread of the second 
summer. In this city, nearly every infant taken from the breast between 
the months of April and October very soon becomes affected with diar- 
rhoea, which, if not inflammatory in its commencement, soon becomes such. 
Weaning in the cool months involves less danger, but even then the suc- 
ceeding summer is one of peril. I have memoranda of the time of wean- 
ing in forty-six infants who were affected with diarrhoea aj)parently from 
its duration and obstinacy of an inflammatory character. 

Woanod in spring or summer, ....... 35 

" " autumn or winter, ....... 11 

46 

The reader is referred, for other particulars in reference to weaning, to 
the chapter devoted to this subject. 

The above facts and statistics, to which more might be added, suffice to 
show the causative relation of foul atmosphere and injudicious feeding to 
the intestinal inflammation of infancy. 

Intestinal inflammation also occurs as a complication of certain diseases, 
especially the eruptive fevers. It is the opinion of some, that in measles 
and scarlatina thei-e is mild inflammation of the intestinal mucous mem- 
brane, coexisting with the eruption upon the skin, and disappearing with 
it. But in a proportion of cases, most frequently in measles, a more in- 
tense inflammation arises, constituting a serious complication. The pecu- 
liar intestinal inflammation in typhoid fever is well known. 

Age. — My observations in reference to the age at which this disease 
occurs were made in the summer months, and, therefore relate to the sum- 
mer epidemic. The cases embraced in the following table were nearly all 
observed between the months of May and October inclusive : 

Age. Numlier of cases. 

5 months or under, . . . . . . . .58 

From 5 months to 12, 212 

•' 12 " 18, 174 

^'18 " 24, 93 

^' 24 " 86, 36 

Total, 576 

This table shows that the infant under the age of six months is less 
liable to entero-colitis than between the ages of six months and two years. 
The small comparative number, however, affected under the age of six 
months, I attribute to the fact that most of the infants under this age 
were wet-nursed. Observations made in the institutions of this city in 



SYMPTOMS. 617 

which foundlings are received show that, the younger the infant is, the 
more liable it is to be affected with this disease, under unfavorable condi- 
tions of atmosphere and diet. Thus, in the infant's service of Charity 
Hospital, prior to the adoption of wet-nursing, a large proportion of the 
foundlings received died of well-marked entero-colitis in the first and 
second months, and very few lived till the age of six months. A similar 
fact was observed in the New York Infant Asylum in Bloomingdale.^ 
During my term of service in this institution I preserved notes of forty- 
nine fatal cases, which I diagnosticated entero-colitis, and in many of 
which post-mortem examinations were made. Of these cases eighteen 
were one month old or under, fifteen from one month to three, eight from 
three to six, and only eight over the age of six months. 

Symptoms. — Intestinal inflammation in the infant usually commences 
with moderate diarrhoea. At first there may be no appreciable anatom- 
ical alteration of the raucous membrane except simple turgescence of the 
follicles. The number of evacuations at this period frequently does not 
exceed four to six daily. The color and consistence of the dejections 
vary. The color is sometimes yellow at this early stage of the disease, 
and sometimes green, especially in young infants. Whatever the color or 
appearance of the stools, there is great uniformity in one respect, and that 
is their acidity. Litmus-paper is i-eddened by them, and they have a 
decidedly acid odor. Often there is from the commencement more or less 
fretfulness and febrile reaction. 

In a few days, the disease continuing, the infant, whose stomach was at 
first retentive, begins to vomit. This symptom I found, from observations 
made in 1863 and 1864, in the summer entero-colitis of infants, commences 
in less than a week in the majority of cases, though the time varies greatly. 
In consequence of the vomiting and diarrhoea the patient becomes pallid, 
the flesh soft and flabby, and soon there is evident emaciation. If there 
is fretfulness in the beginning of the sickness, it now ceases, and the pa- 
tient lies quiet, having an exhausted appearance. As the disease advances, 
the features become pinched and wrinkled. The hollowness of the cheeks 
and sunken state of the eyes are in striking contrast with the appearance 
presented before the inflammation commenced. So feeble is the muscular 
tonicity in advanced cases, that the orbicularis oris and orbicularis palpe- 
brarum lose in great part their contractile power, and the mouth and eyes 
continue open during sleep. 

In the beginning of the disease the tongue is moist and covered with a 
light fur. At a more advanced stage it is dry, and in dangerous forms of 
entero-colitis the buccal membrane is red, the gums swollen and sometimes 
ulcerated, and in young children thrush is apt to appear. 

1 This institution was discontinued within a year from its establishment, all con- 
nected with it becoming discouraged from the great mortality of the foundlings, 
who were chiefly bottle-fed. 



618 INTESTINAL INFLAMMATION OF INFANCY. 

Voniiting, coiuiuencing, as I have said, at a later period than the diar- 
rhoea, coutiuues, unless relieved by medication or a favorable change of 
the disease. It is sometimes very intractable. It is in most cases associ- 
ated with an excess of acid in the stomach, and is probably mainly due to 
this, except at an advanced stage of the inflammation. The substance 
vomited has a sour odor, and produces a decided reaction with litmus- 
paper. It contains coagulated casein and undigested particles of whatever 
food has been given. When the vital powers are much reduced and the 
inflammation has been protracted for some weeks, or is unusually violent, 
spurious hydrocephalus may occur, and the vomiting may then be due to 
this cerebral complication. 

The stools sometimes continue, during the whole course of the entero- 
colitis, of nearly the same character as at first. In other cases they vary, 
at different periods, in color as well as consistence. They sometimes have 
a putty-like appearance, from the partly digested casein ; at other times 
they are brown and offensive. A very common appearance is that which 
has been likened to spinach or chopped vegetables; occasionally the stools 
consist largely of mucus, with perhaps a little blood, — the mucous diarrhoea 
of Barrier. This occurs when colitis is a principal part of the disease. 
The evacuations are seldom so watery as in true cholera infantum. 

Occasionally they are yellow when passed, but become green on ex- 
posure to the air, or from chemical reaction resulting from admixture of 
the urine. 

The microscopic character of the stools in entero-colitis is interesting. 
Aside from undigested casein, I have found unaltered fibres of meat, crys- 
talline formations, epithelial cells, single or arranged regularly in clusters, 
as if detached from the villi, mucus, sometimes blood, and, in one case, 
an appearance resembling three or four crypts of Lieberkuhn united. If 
the stools are green, colored masses of various sizes, but mostly small, are 
also seen with the microscope. The microscopic elements, then, are the 
excrementitious substances, particles of undigested food, inflammatory 
products, and epithelial cells or fragments of the mucous membrane, 
thrown off by the inflammatory process. 

The puke in entero-colitis is accelerated. There is frequently increased 
heat of surface in the commencement, but, as the disease continues, the 
vital powers soon become reduced, and the surface is either of the natural 
temperature or cool. As death approaches, the pulse gradually becomes 
more frequent and feeble, and the extremities, sometimes for hours before 
life is extinct, have a cadaverous pallor and coldness. The skin, in in- 
testinal inflammation, is generally dry, and the urinary secretion di- 
minished. In severer forms of the disease, attended by frequent evacu- 
ations from the bowels, the infant does not pass its urine oftener than once 
or twice daily/ The imperfect action of the skin and kidneys is a note- 
worthy feature of the inflammation. The advanced stages of entero- 



SYMPTOMS. 619 

colitis are apt to be complicated by two cutaneous affections, namely, 
erythema between the thighs, probably produced by the acid and irritating- 
character of the stools, and boils upon the forehead and scalp. The latter 
sometimes extend down to the pericranium, and leave permanent depressed 
cicatrices. The external irritation caused by the furuncular affection has 
often seemed to me conservative, as it occurs at the time when there is 
danger of passive congestion of the brain and serous effusion. When 
entero-colitis is protracted, and the patient is much reduced, remaining 
constantl}^ in the recumbent position, except when held in the arms of the 
mother or nurse, another symptom frequently arises, namely, a dry cough, 
which continues till the close of life, if the case be fatal, and subsides 
slowly if the disease terminate favorably. The complication which gives 
rise to this symptom will be considered hereafter. As death approaches, 
the infant sometimes becomes more fretful ; it turns peevishly from play- 
things, rolls its head, or the head has an unsteady movement ; and often 
the stomach becomes more irritable. The experienced physician rightly 
interprets these symptoms as the forerunner of cerebral accidents. In 
other cases there is too great prostration even for the exhibition of restless- 
ness, and the patient lies quiet. As death approaches, the infant becomes 
drowsy. The limbs are cool. It refuses to nurse, or, if spoon-fed, takes 
nutriment apparently without relish. The pupils are contracted, and in- 
sensible to light. The eyes are bleared, and a puriform secretion occa- 
sionally collects between the lids. The stools are less frequent, and the 
vomiting, if previously present, ceases. Death occurs quietly. 

Sometimes, however, convulsive movements precede death, generally 
slight, as of one arm, or of the limbs or one side. Uraemia may be the 
immediate cause of death in certain cases. 

In chronic entero-colitis there is extreme emaciation for a considerable 
time before death. The skin of the extremities lies in wrinkles ; the joints, 
from contrast, appear enlarged, and the fingers and toes elongated ; the 
angular projections of the bones are prominent. The hollowuess of the 
cheeks and eyes causes the infant to appear much older than it really is. 
Death occurs in a state of extreme exhaustion. 

The above description applies to infantile entero-colitis, as it so fre- 
quently occurs in the cities. It is sometimes much more violent, attended 
by ruuch greater febrile I'eaction, and is more speedily fatal. Especially 
is this the case when it is due to the impression of cold : such cases are not 
infrequent in the winter months, in the country as well as city. 

Instead of the mild and gradual commencement which I have described, 
infantile entero-colitis may be preceded by violent symptoms, — a true 
cholera morbus. Vomiting and purging, more or less severe, precede the 
inflammation. Among my records are cases which commenced in the 
summer season from eating gooseberries, currants, cherries, and cheese : 



620 INTESTINAL INFLAMMATION OF INFANCY. 

the choleraic symptoms produced by these indigestible substances ending 
in protracted inflammation. 

Anatomicai> Chakacters. — BiHard says : "In eighty cases of inflam- 
mation of the intestines that I examined with great care, there were thirty 
of entero-colitis, thirty-six of enteritis, and fourteen of colitis." M. Le- 
gendre, in twenty-eight cases of diarrhoea, found colitis alone in nine, and 
in the cases in which enteritis occurred colitis was also present. Rilliet 
and Barthez state, that in certain rare instances almost the entire diges- 
tive tube is affected ; that in exceptional cases the principal lesion is found 
in the small intestines, while, on the other hand, the large intestine is the 
part of the alimentary canal which is most frequently and intensely in- 
flamed. Billard describes four kinds of intestinal phlegmasia: first, ery- 
thematic; second, with altered secretion; third, follicular; fourth, with 
disorganization of tissue. In some of the best works on diseases of chil- 
dren, published subsequently to that of Billard, diflTerent forms of inflam- 
mation are described, according to the presence or absence of certain ana- 
tomical changes, as ulceration or softening. Practically little is gained by 
such a division of the general disease, and the lesions which are made the 
basis of the division are often merely the result of severe and protracted, 
simple or erythematic, inflammation. I have records of the post-mortem 
appearances in eighty-two cases of intestinal inflammation in the infant. 
Eleven of these occurred in private or dispensai-y practice ; about fifty in 
the Nursery and Child's Hospital, and the remainder in the Infant Asy- 
lum. Since preserving these records, I have witnessed a larger number of 
post-mortem examinations of infants who died of this disease chiefly in 
institutions, and the lesions corresponded in general with those already ob- 
served. The question may properly be asked, can inflammatory hyper- 
ajmia of the intestinal mucous membrane be distinguished from simple 
congestion if there is no ulceration and no appreciable thickening of the 
intestine? This is sometimes difficult, and it is possible that occasionally 
I have recorded as inflammatory what was simply a congestive lesion, but 
I do not think that I have incorporated a sufficient number of such cases 
to vitiate the statistics. In a large proportion of the autopsies there was 
manifest thickening of the intestinal mucous membrane or other unequiv- 
ocal evidence of inflammation. The following is an analysis of the eighty- 
two cases : 

The upper part of the small intestine, embracing the duodenum and 
jejunum, was found inflamed in twelve cases. It was free from inflamma- 
tion, and of a pale color, in fifty-one cases. The ileum was inflamed in 
forty-nine cases, and the ccecal portion, including the ileo-ccecal valve, was 
the part in which the inflammation was uniformly most intense, and to 
which it was often confined. In sixteen eases there was no ileitis, and in 
thirteen no enteritis whatever. Therefore, the ileum was inflamed in all 
but three of the cases of enteritis, in which the records give the exact lo- 



\ 



ANATOMICAL CHARACTERS. 621 

cation of the disease. lu fourteen cases there was vascularity in streaks or 
in patches, or simple arborescence in some part of the small intestines, the 
records not stating its exact location. 

In most cases the inflamed mucous membrane was perceptibly thickened. 
Occasionally, especially if the vascularity was slight, the thickening was 
scarcely appreciable. In one case there was so much thickening of the 
ileum next to the ileo-coecal valve that the raucous coat appeared as if 
closely studded with small warts. Ulcers of small size were found in the 
mucous membrane of the small intestines in five cases. These ulcers in 
one case were in the jejunum, in two in the ileum, and in two in both these 
"divisions of the intestine. They were for the most part quite superficial, 
and circular or oval. 

It is seen from the above records that the portion of the small intestine 
most frequently inflamed was the ileum. The inflammation usually affected 
the ileo-coecal valve, and extended from it to a greater or less extent along 
the small intestine. In general, when inflammatory patches were found in 
different parts of the small intestine, those in the ileum nearest the ileo- 
coecal valve presented the greatest vascularity and thickening. Billard 
noticed in his cases the frequency and intensity of the inflammation in the 
terminal portion of the ileum, and the consequent thickening of the ileo- 
coecal valve, and conjectured that the vomiting so common and obstinate 
in enteritis might be due to obstruction at the ileo-coecal orifice in conse- 
quence of this thickening. I have often seen the orifice reduced to a very 
small size from the hypersemia and thickening of the valve, but have not 
seen any accumulation above it or other evidence of obstruction. 

The inflamed mucous membrane was softened in greater or less degree 
according to the intensity of the inflammation. Sometimes the vessels of 
the submucous connective tissue were injected, and this tissue. infiltrated. 
The softening of the mucous coat, and the firmness of its attachment to 
the parts underneath, varied considerably in different specimens. I was 
able, in cases in which there was considerable softening, to detach readily 
the mucous coat with the nail or back of the scalpel, within so short a 
period after d'eath that it was evident that the change of consistence could 
not have been cadaveric. 

The infants in whom the duodenum and jejunum presented the inflam- 
matory lesions were, with few exceptions, under the age of three months, 
and in many of these cases there was hypenemia of the gastric nuicous 
membrane, and in some also stomatitis. 

In all the cases except one, namely, in eighty-one, there were lesions indi- 
cating inflammation of the mucous membrane of the colon. In thirty-nine, 
the inflammation had affected nearly or quite the entire extent of this por- 
tion of the intestine ; in fourteen, it was confined to the descending portion 
entirely, or almost ciititelv ; in twenty-eiglit cases, the records state that 
colitis was present, but its exact location was not mentioned. In eighteen 



622 INTESTINAL INFLAMMATION OF INFANCY. 

of the examinations, the mucous membrane of the colon was found ulcer- 
ated. According to the statistics, there is colitis in nearly every case of 
intestinal inflammation in infancy, and in a large proportion of cases also 
ileitis. The portion of the colon which is most frequently inflamed is that 
in and immediately above the sigmoid flexure. If the colitis affects other 
j^ortions also, it is nevertheless in this part that we find the most marked 
inflammatory lesions. 

The solitary glands, both of the large and small intestines and Peyer's 
patches, are involved in nearly all cases of this disease. Even in non-in- 
flammatory diarrhffia they become tumefied, so as to be distinctly visible 
and somewhat elevated. In entero-colitis, as we have already seen, they 
pi-eseut different appearances, according to the degree and duration of 
the inflammation. In recent cases, and in parts of the intestine where 
the inflammatory action has been mild, there is often no perceptible change 
of these glands except slight enlargement with vascularity. This enlarge- 
ment is most apparent if the intestine is viewed by transmitted light, when 
not only the glands are seen to be swollen, but their central dark points 
are also quite distinct. If there is a higher grade of inflammation, or 
inflammation more protracted, the volume of the solitary follicles is so 
increased that they rise above the common level and present a papillary 
appearance. Peyer's patches are in a corresponding degree thickened. 

The enlargement of these glands is due to hyper])lasia, namely, an 
augmentation in the number of the elementary cells. The ulceration in 
the cases which I have examined appeared to be primarily and chiefly 
follicular. While some of the solitary glands in a specimen were found 
simply tumefied, others were slightly ulcerated, and others still nearly or 
quite destroyed. The ulcers were usually from one to three lines in 
diameter, circular or oval, with edges a little raised, and red. They re- 
sembled in appearance the ulcers in follicular stomatitis. In one or two 
instances I have seen small coagula of blood in the ulcers, and I have also 
seen ulcers which have evidently been larger, having partially healed. 
The principal seat of the ulcers was in the descending colon. They were 
either found in this portion of the intestine only, or, if occurnng elsewhere, 
they were here most abundant. 

Those in whom I have found ulcers have been ordinarily over the age 
of six months, which is the time when there is greatest development and 
activity of the glandular apparatus. In none of the cases observed by me 
were Peyer's patches ulcerated, though generally tumefied. 

In cases in which the caput coli was inflamed, I have sometimes found 
the mucous membrane of the appendix vermiformis also injected and 
thickened. In one case only was there pseudo-membrane upon the in- 
flamed surface. This was in the descending colon, and it was thin like a 
film. The rectum presented no inflammatory or other lesions, or but 
slight lesions in comparison with those in the colon. Often, when there 



ANATOMICAL CHARACTERS. 623 

was almost general colitis, the rectum was found of a pale color, or but 
slightly vascular. This may explain the rare occurrence of tenesmus in 
infantile entero-colitis. The amount of mucus secreted from the intestinal 
surface in this disease is considerably in excess of the normal quantity. It 
often forms a layer upon the mucous membrane of the intestines, and ap- 
pears in the stools, mixed with epithelial cells and sometimes with blood 
or pus. If the quantity of mucus appearing in the stools is considerable, 
the disease has sometimes been designated mucous diarrhoea, or mucous 
disease; but there does not seem to me sufficient reason, either anatomical 
or clinical, for considering it a distinct malady. 

The mesenteric glands are ordinarily enlarged, unless in very young in- 
fants. They are frequently found as large as a large pea, or even larger, 
and of a light color, from the anseraic state of the infant. In exceptional 
instances certain of them are found to have undergone cheesy degeneration. 
The enlargement of these glands, like that of the solitary follicles and 
Peyer's patches, occurs from hyperplasia. The condition of the stomach Avas 
recorded in sixty-nine cases. In forty-two it was healthy ; in seventeen 
red, apj)arently inflamed; in seven of a pink color; and in three it con- 
tained ulcerations, probably cadaveric. The usual healthy condition of the 
stomach is a noteworthy fact, taken in connection with the frequent vomit- 
ing, in entero-colitis. I have stated elsewhere that stomatitis is also a com- 
mon complication in protracted and grave cases, accompanied by spongi- 
ness of the gums, which bleed if pressed or rubbed. The buccal surface in 
these cases is more vascular than natural, and, if the vital powders are 
much reduced, superficial ulceration is not infrequent, especially of the 
gums. In infants under the age of three or four months, oesophagitis is 
also a common accompaniment of entero-colitis. 

Thrush, though a frequent complication under the age of three or four 
months, is rare in older infants. Thrush, in infants over the age of eight 
or ten months, occurring in connection with intestinal inflammation, is an 
unfavorable prognostic sign, indicating a gravity of the intestinal disease 
which commonly eventuates in death. 

There exists an opinion in the profession that the liver is in fault in this 
disease, especially in that form of it which I have described as a summer 
epidemic of the cities. This opinion is, probably, less prevalent than for- 
merly, but it is still held by many, and it influences the choice of thera- 
peutic agents. 

I have notes of the appearance and state of the liver in thirty-two fatal 
cases of the epidemic entero-colitis of the summer season. Nothing could 
be seen in these examinations that indicated any disturbance in the func- 
tion of this organ. The size of the liver was in some cases very different in 
those of about the same age, but probably there was no greater diflerence 
than usually obtains among glandular organs within the limits of health. 



624 INTESTINAL INFLAMMATION OF INFANCY. 

The following table gives the weight of the liver in twenty cases in which 
the weight of this organ and the age of the patient are recorded : 



Age. 




Age. 




4 wcrks 


5 ounces. 


10 months . 


fil ounces, 


2 months . 


. 3i " 


13 " 


6 " 


2 " 


. 3^ " 


14 " 


9 


4 " 


5 " 


15 " 


6 


5 " 


Gi " 


15 " 


• 'h " 


5 " 


9 " 


15 " 


9i " 


7 " 


n " 


16 " 


6 


7 " 


6 " 


19 " 


. U " 


7 " 


. H " 


20 " 


. 9i " 


9 '^ 


8 " 


2o " 


. 15 " 



I do not have acce.ss to tables giving the weight of the healthy liver at 
different ages, but in none of the above examinations did the size or the 
weight seem to me to be above the healthy standard, except in one, in which 
this organ w\as quite fatty. But in this case the degeneration and enlarge- 
ment of the liver were doubtless due to tuberculosis. 

In most of the cases the liver was examined microscopically, and the 
only fact worthy of note obsserved was the variable amount of fatty matter. 
Sometimes it was in excess, sometimes in moderate quantity or rather de- 
ficient, and sometimes in greater amount in one portion of the organ than 
in another. 

The prevalent belief, then, that the liver is greatly affected in the sum- 
mer epidemic of entero-colitis, receives no corroboration from the inspection 
of this organ. The only pathological state (if it be such) observed in it 
relates to the amount of oily matter, and this obviously requires' no special 
treatment. 

The cutaneous affections complicating entero-colitis have already been 
alluded to. 

Frequently at post-mortem examinations of infants who have died of 
entero-colitis, intussusceptions ai'e found in the small intestines. These 
pro])ably in general occur at the moment of, or not long before, death, as 
they are small and readily reduced, but I have in a few instances found 
intussusceptions which sustained the weight of two feet or more of intestine 
without being reduced, and which, from being in their interior more vascu- 
lar than the contiguous membrane either above or below, probably occurred 
some hours, possibly days, before death, but, being sufficiently pervious to 
allow the food to pass, symptoms of obstruction were absent. 

It has been said, in speaking of the symptoms, that a cough is common 
in protracted entero-colitis when the vital powers are greatly reduced, and 
the cii-culation is feeble. From the great emaciation and the character of 
the cough, the physician as well as friends is very apt to suspect the pres- 
ence of tubercles. But tuberculosis is quite exceptional in these cases. I 



DIAGNOSIS. 625 

have preserved the records of eighty-two post-mortem examinations of 
infants who died of entero-colitis in the summer months, and tubercles 
were fovmd in only one case. The cough was due to solidification of the 
posterior and dependent portion of one or both lungs. The exact patho- 
logical character of this solidification of lung (hypostatic pneumonitis) is 
treated of in our remarks on diseases of the respiratory organs. 

In the cases of entero-colitis which were complicated with this state of 
the lungs, I have not usually found enough of the lung-tissue involved to 
make any perceptible difference in the sound on percussion. Its extent of 
solidification was sometimes not more than two or three lines, and frequently 
not more than a quarter to half an inch in an antero-posterior direction, 
although it embraced nearly or quite the entire posterior surface of the 
organ . 

The state of the brain in the entero-colitis of infancy is interesting to 
the pathologist. When the disease is protracted, this organ wastes like 
the body and limbs. In the young infant, in whom the cranial bones are 
still ununited, the occipital and sometimes the frontal become depressed in 
proportion to the loss of brain-substance, so that the cranium is quite un- 
even. In older children with the cranial bones consolidated, serous effu- 
sion occurs according to the degree of waste, thus preserving the size of 
the encephalon. The effusion is chiefly external to the brain, extending 
on each side over the convolutions from the base to the vertex. The quan- 
tity of serum varies fi'om one to two drachms to an ounce, or even more. 
The serous effusion is. associated with passive congestion of the cerebral 
vessels and cranial sinuses, and this jDathological state when sufficient to 
produce symptoms, is the common form of spurious hydrocephalus. 

Diagnosis. — The only disease with which infmtile inflammation of the 
intestines is likely to be confounded is non-inflammatory diarrhoea. There ' 
is no pathognomonic sign or symptom, in the majority of cases, in either 
malady, excejDt constant elevation of temperature, when inflammation is 
present. Occasionally we are able to diagnosticate colitis from the presence 
in the stools of mucus, or mucus tinged with blood. Abdominal tender- 
ness, which in the adult is so important a diagnostic symptom of intestinal 
inflammation, is generally absent in the infant, or, if present, is not easily 
ascertained. Febrile movement in connection with persistent diarrhoea 
indicates intestinal inflammation. 

In general I have found that, if diarrhoea continued more than a week 
in the summer season, it had become inflammatory. Sometimes, however, 
as I have in certain instances observed, diarrhoea may continue for a much 
longer time, attended by extreme emaciation and terminating fatally, and 
yet at the post-mortem examination no lesion of the intestines be found, 
except a tumefied state of the intestinal glands. Practically it matters 
little whether we ascertain the inflammatory or non-inflammatory character 

40 



626 INTESTINAL INFLAMMATION OF INFANCY. 

of the disease, as we determine the proper mode of treatment from the 
symptoms and general condition of the patient. 

Prognosis. — Though intestinal inflammation is one of the most fatal 
infantile maladies, still, by proper hygienic measures and a judicious selec- 
tion and use of medicines, a large proportion of those affected may be 
saved. This inflammation and most of its complications are of such a 
nature that we may have reasonable hope that the infant will recover if 
suitable measures are employed sufliciently early. Many do recover from 
a state of emaciation and feebleness which, occurring in any other patho- 
logical state, would be almost necessarily fatal. The most unfiivorable 
symptoms in this disease, excejJt those due to extreme prostration or col- 
lapse, arise from the state of the brain. Rolling the head, squinting, 
feeble action of the pupils, spasmodic or irregular movements of the limbs, 
indicate the near approach of death. There are many facts which should 
be taken into consideration in making a prognosis. The age of the infant, 
the time in the year, the surroundings, especially in reference to the im- 
purity of the atmosphere, are to be considered, as well as the present state 
of the patient. 

Intestinal inflammation of infancy might, in many instances, be prevented 
by judicious measures. Especially is it preventable in those cases in which 
the exciting cause is dietetic. The reader is referred to the chapters on 
weaning and artificial feeding, for facts in reference to this matter. Un- 
fortunately, however, the physician is not generally consulted in regard 
to the alimentation of the infant, or the time and manner of weaning, or 
other important matters of regimen, until diarrhoea, inflammatory or non- 
inflammatory, is established ; his purpose is then not to prevent, but to 
cure. 

Treatment, — Begimenal Measures. — Intestinal inflammation of in.- 
fancy requires somewhat different treatment, according to the cause, as 
well as the condition of the patient. If it occur in an infant of previous 
good health, and from exposure to cold, its diet should at first be reduced. 
If it be nursing, it should take the breast less frequently. It will then 
receive less nutriment, not only in consequence of the longer interval 
between the times of nursing, but because the milk remaining in the breast 
becomes more watery and less nutritious. If thirsty, it may take a little 
light barley-water or gum-water. If the infant be weaned, a corresponding 
reduction in its nutriment should be made. 

These cases require emollient and slightly irritating applications over 
the abdomen, as by a flaxseed poultice to which a little mustard is added. 
After the acute stage has passed, more frequent nursing and more nutri- 
tious diet should be allowed. Often the alcoholic stimulants in barley- 
water, and sometimes the animal broths, are required in this stage of the 
disease. Exhaustion should be guarded against in the infant. 



TREATMENT. 627 

As a chief cause of infantile entero-coiitis, especially in the city, is the 
use of food which is with difficulty digested, and which therefore becomes 
irritating, it is of the first importance in the treatment of most cases, which 
are not referable to exposure to cold, to give particular attention not only 
to the nature of the food, but to the mode of its preparation and the quan- 
tity given. To the young infant with entero-colitis, no food is so easily 
digested, and is therefore so suitable, as human milk. The bottle-fed in- 
fant, under the age of twelve months, remaining in the city in the summer 
season, and affected with intestinal inflammation, cannot in general be 
successfully treated unless it is provided with a wet-nurse. Frequently, 
when the diarrhcea continues in spite of all other measures hygienic and 
medicinal, the infant begins at once to improve by the employment of a 
wet-nurse, so that it is sometimes really surprising to observe as a conse- 
quence of this measure the rapid and complete restoration to health from 
a state of extreme emaciation. 

In certain cases the breast-milk, either of the mother or wet-nurse, dis- 
agrees with the infant, and its use aggravates the intestinal disease. In 
the country, or in the cool months in the city, w^eaning may be proper 
under such circumstances. Certaiuly weaning or the employment of an- 
other wet-nurse is required. In the city in the summer months, for reasons 
elsewhere fully stated, weaning is a very injudicious if not fatal measure, 
and, if the entero-colitis is aggravated by the character of the mother's 
milk, a wet-nurse should be engaged. If the breast-milk is suspected as 
the cause or one cause of the infant's sickness, it should be examined by 
the microscope, before a change in diet or in nursing is recommended. It 
has been ascertained by the microscope, that the elements of colostrum 
whi«h have a purgative effect may return at any period of lactation. 

If the mother's milk disagrees, and a wet-nurse for any reason is not 
employed, it is then necessary to recommend a diet which will be the best 
possible substitute for the natural aliment. Wheat flour boiled dry in a 
bag for twenty-four hours. Ridge's food, the basis of which is wheat flour, 
Hawley's, Liebig's food, the upper third of cow's milk when it has stood two 
or three hours, the expressed juice of lean beefsteak slightly roasted, and 
scraped raw beef, may be mentioned among the articles of diet which I 
have found useful in these cases. For facts in reference to artificial feed- 
ing, and for dietary formulce, the reader is referred to chapters relating to 
the diet of infancy. 

Attention to the diet of infants affected with intestinal inflammation is 
obviously of the utmost importance, but one chief cause of the disease, es- 
pecially of the great summer epidemic of the cities, we have seen to be 
atmospheric. This requires attention on the part of the practitioner to a 
different matter in the hygienic management of these cases, namely, the 
state of the air which the infant breathes. lu the cool months, the atmos- 



628 INTESTINAL INFLAMMATION OF INFANCY. 

phere is more pure than in the summer montJis, as it contains less of those 
noxious gases which arise from decaying animal and vegetable substances. 
In those months, then, in which the weather is such that there is no decom- 
position of organic matter, the atmospheric cause of entero-colitis is not 
operative, and little is gained for the patient by change of locality. But 
in the summer season one of the most important conditions of successful 
treatment of this and the other diarrhoeal maladies of infancy is the re- 
moval of patients from an impure to a pure atmosphere. Physicians of 
exj^erieuce all agree in the choice of elevated localities, containing a sparse 
population, and remote from the seashore. Many are the instances every 
summer in this city of infants removed to the country with intestinal in- 
flammation, with features haggard and shrunken, with limbs shrivelled, 
and skin lying in folds, too weak to raise or at least hold their heads from 
the pillow, vomiting nearly all the nutriment taken, with stools frequent 
and thin, resulting in great measure from molecular disintegration of the 
tissues, presenting indeed an appearance seldom seen in any other disease 
except in the last stages of phthisis, and returning in late autumn, with the 
cheerfulness, vigor, and rotundity of health. The localities usually pre- 
ferred by the physicians of this city are the elevated portions of New 
Jersey and Eastern Pennsylvania, the Highlands of the Hudson, the cen- 
tral and the northern parts of New York State, and Northern New Eng- 
land. Taken to a salubrious locality, the infant will soon begin to im- 
prove after it has recovered from the fatigue of travelling, unless the case 
is incurable. 

Sometimes parents, not noticing the immediate improvement which they 
had been led to expect, return to the city without giving the country fair 
trial, and the life of the infant is almost necessarily sacrificed. Returned 
to the foul air of the city while the weather is still warm, it sinks rapidly 
from an aggravation of the malady. Dr. James Jackson recommends, if 
the infant do not improve where it is taken, that it should be conveyed to 
another locality. This is good advice, provided that the selection be made 
of a place elevated, remote from the seashore, and having a sparse popula- 
tion. The infant, although it has recovered, should not be brought back 
while the weather is still warm. One attack of the disease does not di- 
minish but increases the liability to a second seizure. 

If the situation of the family is such that it is not practicable to take 
the infant to the country, and such cases are frequent among the poor, it 
should be kept much of the time in the open air ; it is a common practice 
in this city to take such patients in the daytime to the seashore, or upon 
ferry-boats. Dr. E. H. Parker says : " Many of my patients are sent to 
the ferries to cross them, so that the cool, fresh, sea-breeze may fan them, 
and it acts sometimes like magic, to raise their drooping heads." I have 
not observed such marked benefit in these cases from the sea-breeze as 



\ 



TREATMENT. 629 

from the air of elevated localities, which can generally be found in the 
vicinity of cities, and are easily accessible. 

Medicinal Treatment. — Sometimes it is proper to commence treatment 
by the employment of a gentle purgative, particularly when the disease 
commences abruptly from a state of previous good health. It is then 
frequently caused by exposure to cold, or more rarely by some indigestible 
and highly irritating substance in the intestines. In such patients there 
is often a full habit. The pulse is strong and quick, the heat of surface 
great, the face perhaps flushed, the stools sometimes slimy and bloody, 
sometimes green or brown. It is proper and often serviceable, when there 
is this commencement of the affection, to give a single dose of castor oil 
or syrup of rhubarb. Any indigestible substance, if present, is removed 
from the intestine, and opiates or other remedies designed to control the 
disease may then be more successfully employed. Such cases occur in the 
winter not less than in the summer, and in all localities, rural as well as 
in the city. But the summer epidemics of intestinal inflammation in the 
cities do not in general require such preliminary treatment. Diarrhoea, 
moderate, perhaps, has already continued for a time when the physician 
is called, and no irritating substance remains except the acid, which is 
abundantly generated in the intestine in this disease, and which we have 
a means of removing without purgation. Preliminary treatment having 
been employed or not, according to the nature of the attack and condition 
of the patient, remedies calculated to arrest the inflammation should then 
be prescribed. 

The medicines which should be employed are chiefly of three kinds, 
namely, alkalies, opiates, and astringents ; sometimes one or two kinds 
only, and sometimes all three, according to the character of the evacua- 
tions. The antacid treatment is, of course, required in those numerous 
cases in which the stools are acid, and there is no better alkaline remedy 
for the diarrhoea in this disease than the preparations of chalk. The creta 
prseparata of the pharmacopoeias, in doses of two or three grains to a child 
one year old, or the mistui'a cretae in teaspoonful doses, are eligible prep- 
arations, and are commonly employed. These medicines should be re- 
peated in two hours, or a longer time, according to the state of the patient. 
Chalk given for a moderate period is innocuous, and may be administered 
to the youngest child. 

In Europe the crab's eye is much used, and it is stated that it is some- 
times eflectual in controlling the disease, wdien the chalk fails. The fol- 
lowing is a formula recommended by Bouchut : 

R. Ocul. cancror. pulv., gr. x. 
Aq. foeniculi, 
Syr. rhei, jia gss. M. 
One teaspoonful every hour. 



630 INTESTINAL INFLAMMATION OF INFANCY. 

In this country the same antacid has been also employed, though less 
frequently than the preparations of chalk. J. F. Meigs, of Philadelphia, 
prescribes it as follows : 

R. Ocul. cancror. pulv., ^j. 
AoaciiB pulv., gij. 
Sacch. alb., Qj. 
Aq. fontis, 

Aq. cinnamom., aa §iss. M. 
A teaspoonful four, five, or six times daily. 

By means of this alkali alone, aided by proper hygienic measures, the 
disease is sometimes arrested, but, unless circumstances are favorable and 
the case is mild, other medicines are required. 

Opium is used by most practitioners in the treatment of this malady. 
Either as a main remedy or adjuvant it is employed, and properly, in 
nearly all severe cases. For a young infant paregoric is an eligible prep- 
aration of opium. For the age of one month, the dose is three to five 
drojDS ; for the age of six months, ten to twelve drops, repeated in three 
hours or a longer time, according to the state of the patient. After the 
age of six months the stronger preparations of opium are more frequently 
used. At the age of one year the liq. opii corapositus or tincture opii 
may be given in doses of one to two drops. Dover's powder is also an 
excellent medicine in this disease, given in doses of three-fourths of a grain 
to an infant one year old. 

Opium is, however, in general best given in mixtures which will be men- 
tioned hereafter. It quiets the action of the bowels, and diminishes the 
number of evacuations. It is contraindicated or should be used with 
caution if cerebral symptoms are present. Sometimes in the commence- 
ment of the disease, if there is much febrile reaction, the patient may be 
drowsy and in danger of convulsions. Then opiates should be given cau- 
tiously or withheld. Also in the advanced stages of this disease, when, 
perhaps, there is more or less serous effusion in the cranial cavity, opium 
should be cautiously used, as it might tend to produce that fatal stupor, in 
which unfavorable cases are apt to terminate. 

Astringents are required when the evacuations are thin and frequent, 
and are not sufficiently controlled by the remedies already mentioned. 
Those of a vegetable nature are usually preferred, as they are compatible 
with chalk, and may be given in combination with it. The astringents 
commonly used are, catechu, kino, krameria, tannic and gallic acids. Log- 
wood and blackberry roots are also occasionally employed. I prefer, how^- 
ever, the subnitrate of bismuth in large doses, to any of these. 

If the inflammation become chronic, nitrate of silver and acetate of 
lead are sometimes useful. Astringents should not be given if the stools 
are scanty and consistent though frequent, nor should they be employed if 
the evacuations are muco-sanguinolent, as in the dysentery of the adult. 



TREATMENT. 631 

I will now mention various combinations of medicines which have been 
found the most useful in this inflammation. 

In all those cases in which the evacuations consist chiefly of mucus, or 
mucus and blood, from the predominance of colitis, and in all recent cases 
in which the evacuations are scanty, and there is considerable fever, one of 
the best formulae is the following, which is similar to that recommended by 
Dr. West : 

R. Tine, opii, gtt. xvj. 
Pulv. gum acac, 
Pulv. sacch. alb., aa ^j. 
01. ricini, gj to ^ij. 
Aq. cinnamom., ^iss. Misce. 
One teaspoonful every three hours to an infant of one year. 

In these cases, also, Dover's powder, given at the same interval with an 
occasional small dose of castor oil, will have a good eflect in controlling 
the inflammation. 

In the more common forms of intestinal inflammation, including those 
cases which occur in the summer months, from dietetic and atmospheric 
causes, a somewhat different course of treatment is required. The stools 
may be yellow, green, or brown, but are free, more frequent than natural, 
and thin. In these cases the compound powder of chalk with opium, com- 
bining as it does an alkali, opiate, and astringent, will be found useful. 
The subnitrate of bismuth is also a valuable remedy, not only for this dis- 
ease, but also for cholera infantum, and one which is appropriate in most 
cases. It has indeed long been used in the diarrhoeal maladies of infancy, 
but in doses much too small. Its effects are believed to be entirely local, 
namely, upon the gasti'o-intestinal surface, for there is no evidence of its 
absorption. It undergoes or effects some chemical change in the stomach, 
probably with the secretions, for it becomes black in this organ, and it 
gives a dark tinge and more consistence to the stools. It is at the same 
time an efficient anti-emetic. 

The following are formulse which we have used with the best results in 
the institutions with which I am connected. The dose is for an infant of 
one year : 

U. Tine, opii, gtt. xvj. 

Bismuth subnitrat., ^ij. 
Mistur. cretse, ^^ij. Misce. 
Shake bottle. Dose, one teaspoonful every three hours. 

R- Bismuth subnitrat., gj. 

Pulv. creb. comp. c. opio, ^ss. Misce. 
Divid. in chart No. x. Dose, one powder every three hours. 

R. Bismuth subnitrat., 3J — iss. 

Pulv. ipecac, comp., gr. ix. Misce. 
Divid. in chart No. xii. Dose, one powder every three hours. 



632 INTESTINAL INFLAMMATION OF INFANCY. 

An infant of six months can take half the dose, and one of three or four 
months one-fourth or one-third the dose of either of the above mixtures. 

Eaemata. — These are of great service in many cases of intestinal inflam- 
mation. At any stage of the disease, when the stomach is irritable and 
medicines are not retained, they may be advantageously employed. Lau- 
danum especially is often given in this way to the infant with great benefit. 
It may be prescribed mixed with a little starch-water, and the best instru- 
ment for administering it is a small glass or gutta-percha syringe, the 
nurse retaining the enema for a time by means of a compress. Beck, in 
his Infant Therapeutics, advises to give by injection twice as much of the 
opiate as would be administered by the mouth. A somewhat larger pro- 
portion may, however, be safely employed. Astringents may also be 
given by enema. 

Since the inflammation is ordinarily most intense in the descending 
colon, and is sometimes confined to this portion of the digestive tube, 
benefit results in certain obstinate cases from the injection into the rectum 
of a solution of nitrate of silver in warm distilled water, in the proportion 
of one grain to six or eight ounces. A little laudanum may be added. 
Tliis treatment has been employed in the Nursery and Child's Hospital, 
but only as an adjuvant to remedies administered by the mouth. 

In most of those cases of intestinal inflammation which occur under 
the depressing effect of Avarm weather, alcoholic stimulants are required 
almost from the commencement of the disease, and their use is beneficial 
in chronic or protracted cases, whatever the cause or season. Bourbon 
whisky or brandy is the best of these stimulants, and it should be given 
in small doses, repeated at intervals of two hours. I have usually ordered 
three or four drops to an infant one month old, and an additional drop or 
two drops for each month. The stimulant is not only useful in sustaining 
the vital jwwers, but it also aids in relieving the irritability of stomach. 

In certain cases of entero-colitis vomiting is a jDrominent symptom. It 
is common and often obstinate in cases occurring during the summer epi- 
demic, and it increases greatly the prostration. Sometimes it is probably 
due to excess of acid in the stomach, sometimes is the result of the general 
irritability and increased movement of the gastro-intestinal canal, and 
sometimes it probably has a cerebral origin. The following are formulae 
which will be found useful for this symptom. 

U. Bismuth subnitrat., ^^ij. 
Spts. animon. aromat., ^ss. 
Syr. simplic, 
Aquse, aa ^j. Misce. 
Sluike bottle. Dose, one teaspoonful hourly, or every second hour if required. 

R. Acid, carbolic, gtt. ij. 
Aq. calcis, ^ij. Misce. 
Dose, one teaspoonful with a teaspoonful of milk (breast-milk if the baby nurses), 
to be repeated according to the nausea. 



TREATMENT. 633 

Lime-water alone often removes the nausea when there is an excess of 
acids in the stomach, but it is rendered more effectual in certain cases 
by the addition of carbolic acid, which tends to check any fermentative 
process. 

Another remedy is the neutral mixture, prepared by the following for- 
mula, the bottle being tightly corked immediately on mixing the ingre- 
dients, so as to retain the carbonic acid : 

R- Potass, bicarbonate, gr. xxv. 
Acid, citric , gr. xvij. 
Aq. aniygdal. amarse, gj. 
Aqua3, ^ij. Misce. 
Dose, one teaspoonful to a child from eight to ten months, according to the 
nausea. 

Dr. Sweezey, one of the attending physicians in the class of children's 
diseases at the Outdoor Department at Bellevue, has called my attention 
to the good effects of minute doses of ipecacuanha to relieve nausea in 
this disease, employed in the following formula : 

R. Tinct. ipecacuanba3, gtt. iv. 
AqujB, ^h'. Misce. 
• Dose, one teaspoonful, repeated according to the nausea. 

I ha^e employed all these prescriptions, and in certain cases with a 
satisfactory result, but my preference is for the bismuth in large doses, as 
it seems to aftbrd relief in the largest proportion of cases. Nevertheless 
there are instances, especially during the summer epidemics, when this 
symptom is very obstinate, and all these remedies may fail. In these 
cases perfect quiet of the child, the administration of but little nutriment 
at a time, mustard over the epigastrium, and the use of an occasional 
small piece of ice may relieve the nausea. 

When the disease is chronic, and the vital powders begin to fail, as indi- 
cated by pallor, more or less emaciation, and loss of strength, the follow- 
ing is the best tonic mixture with which I am acquainted. It aids in 
restraining the diarrhoea, while it increases the appetite and strength. It 
should not be prescribed until the inflammation has assumed a subacute 
or chronic character. 

R. Tinct. colombre., giij. 

Liq. ferri nitratis, gtt. xxvij. 
Syr. simplic, ^iij. Misce. 
Dose, one teaspoonful every four hours to an infant of one year. 

In the Outdoor Department at Bellevue we commonly give this tonic 
alternately with the bismuth powders. 

External Treatment. — Some writers recommend depletion by leeches in in- 
testinal inflammation, advice likely to do harm, unless the particular cases 



634 ENTERITIS AND COLITIS IN CHILDHOOD. 

are described in which it may possibly be of service. It can be useful only 
in those cases in which the infant is robust and of full habit, and the disease 
commences suddenly with decided febrile reaction. Such cases are oftenest 
seen with us in the winter season, and even these are ordinarily best treated 
without loss of blood. Sinapisms and poultices usually are sufficient as 
local measures. In these cases, also, the warm mustard foot-bath should 
be employed, and repeated if there is restlessness or cerebral symj^toms. 

In all forms of intestinal inflammation in infancy and in all its stages, 
mild counter-irritation over the abdomen is often useful, but vesication, by 
increasing the restlessness of the infant and reducing its strength, without 
materially modifying the severity or duration of the disease, does more 
harm than good. It is not to be thought of as a remedial measure. I have 
know^n a troublesome sore continuing till death, and probably hastening 
this result, to occur from this treatment. Poultices or fomentations over 
the abdomen are sometimes beneficial, especially those of a mildly irri- 
tating nature. A poultice of powdered cloves, cinnamon, and ginger, or 
of linseed meal to which a little mustard is added, may be employed, or, 
better than either, a linseed poultice spread thin, under which a single 
layer of muslin is placed, saturated with tincture of camphor, and over 
both oil silk. In the entero-colitis of infants, occurring in the cool months, 
and due to exposure to cold, this treatment is especially useful. In the 
epidemic entero-colitis of the summer months, which may be aggravated 
by heat, treatment by jwultices may be injudicious, but in such caises it is 
proper to produce moderate redness over the abdomen by temporary ap- 
plications. 



CHAPTEE IX. 

ENTERITIS AND COLITIS IN CHILDHOOD. 

Intestinal inflammation in childhood differs materially from the form 
or type which it commonly presents in infancy. Its causes, symptoms, and 
extent differ in important particulars in the two periods. In childhood 
there is not ordinarily such extensive inflammation of the mucous mem- 
brane of the intestines as we have seen is present in the majority of cases 
in infancy, and it may, therefore, be properly treated as two diseases, ac- 
cording to the seat of the morbid process, namely, enteritis and colitis. 
Both these affections in the child resemble so closely the form which they 
exhibit in adult life, that no extended description is needed in this con- 
nection. 

Causes. — These are vicissitudes of temperature, especially sudden 



SYMPTOMS. 635 

change from ^Yarm to cold, which checks the perspiration, and causes a 
determination of blood from the surface to the viscera. These inflamma- 
tions are also caused sometimes by irritating substances in the intestines. 
I have known fsecal accumulations as well as worms to produce severe 
dysentery in the child, accompanied by the characteristic tenesmus a'nd 
muco-sanguineous stools, and ceasing as soon as the offending substances 
were expelled. The use of unripe or stale vegetables, if there is a strong 
predisposition to mucous inflammation, may be a sufficient cause, and some 
of the most dangerous cases are due to the accumulation in the intestines 
of seeds and the parenchyma of fruits. But the most common cause is 
that mentioned, namely, sudden exposure to cold when the body is heated, 
a danger to which children are especially liable, on account of the easy 
disturbance of the circulatory system in them, and their heedless exposure 
of themselves, unless incessantly watched. 

Enteritis and colitis are also frequently secondary diseases. They occur 
in children as complications or sequelae of the eruptive fevers, especially 
measles. 

Symptoms. — The alvine discharges in enteritis and colitis in childhood 
are such as occur in these diseases at a more advanced age. In enteritis 
they are thin and of the natural color, or occasionally green ; in colitis 
they are more consistent than in enteritis, and are largely muco-sanguineous. 
Sometimes in enteritis, if the inflammation is not intense, the diarrhoea is 
slow in appearing, or it may be slight, so as not to attract special attention. 
The disease may then resemble remittent fever, for which it is at times 
mistaken. The upper part of the small intestines is less frequently affected 
than the lower. If there is duodenitis, the flow of bile is occasionally im- 
peded from tumefaction at the mouth of the common bile-duct, and the 
icteric hue appears. In both enteritis and colitis there is abdominal 
tenderness, with more or less constant pain if the disease is severe, and in 
colitis, tormina and tenesmus. The pulse is accelerated, the heat of sur- 
face augmented, the face flushed, and, except in mild cases, indicative of 
suffering. In many children at the commencement of the inflammation 
the nervous system is profoundly affected, as indicated by headache, stupor, 
twitching of the limbs, and sometimes by convulsions. The chief danger 
at the commencement of the disease is, indeed, from this source. Some- 
times there is irritability of the stomach, and the food is rejected, though 
much less frequently than in the intestinal inflammation of infancy. 
Anorexia and thirst are common symptoms. If the inflammation con- 
tinue, there is soon perceptible emaciation, with loss of strength. The 
eyes become hollow, the face pale, and the surface cool. Death may occur 
at an early period, the vital powers succumbing from the intensity of the 
inflammation. In other cases, the acute disease ends in a subacute or 
chronic inflammation ; the patient becomes gradually more reduced, till 
he dies in a state of extreme emaciation, such as we often observe in the 



636 ENTERITIS AND COLITIS IN CHILDHOOD. 

entero-colitis of inftincy, or from this state he may recover by degrees, 
though perhaps with an irritable state of the bowels, which continues for 
mouths. In a majority of cases, however, enteritis and colitis in child- 
hood, if not neglected, soon begin to yield, and they terminate favorably in 
one or two weeks. 

DiA(}XOSis. — It is not difficult to determine the existence of the in- 
flammation. This is indicated by the fever, abdominal tenderness, and 
the relaxed state of the bowels. Whether the disease is enteritis or colitis 
is determined by the character of the stools, the seat of the tenderness, and 
the presence or absence of tenesmus. 

Pkognosis. — It has been stated above that enteritis and colitis in children 
commonly terminate favorably. The result depends not only on the extent 
and severity of the inflammation, but the constitution and previous health. 
The inflammation is more serious when secondary than when primary. Ex- 
tensive and great tenderness of the abdomen, features pale, anxious, and 
indicative of sufleriug, pulse frequent and feeble, should excite the most 
serious apprehensions. Frequent vomiting also denotes a grave form of 
the disease. Stupor, and especially convulsive movements, show that the 
nervous centres are affected, and should make us guarded in the prognosis. 
Improvement in the disease, on which to base a favorable prognosis, is ap- 
parent in the diminution of the tenderness, improvement in the pulse and 
character of the stools, a more cheerful countenance, and less disrelish of 
food. 

Treatment. — This should be similar to that employed in the adult. 
In enteritis at the commencement of the disease, if there is reason to sus- 
pect the presence of any irritating substance in the intestines, and ordi- 
narily in colitis, it is advisable to commence treatment by the use of some 
simple evacuant, like castor oil. After this our reliance, so far as internal 
treatment is concerned, must be mainly on opiates, or opiates with dia- 
phoretics. One of the best remedies of this class is the Dover's powder, 
which may be given to a child five years old in doses of three grains every 
three hours. A corresponding dose of any of the other opiates may be 
given, but with less sudorific effect. In colitis the occasional administra- 
tion of a laxative should not be neglected, if the stools are entirely or 
mainly muco-sauguineous. It should be employed so as to prevent ac- 
cumulation of fsecal matters in the colon, which would serve as an irritant 
and increase the inflammation. The dose should be small, merely suffi- 
cient to produce a fpecal evacuation, and repeated as required, daily or 
less frequently. The laxative commonly preferred is Rochelle salts or 
castor oil. The physician may prescribe an opiate mixture containing 
sufficient of the laxative to have the effect desired, though ordinarily it is 
better to prescribe the two separately, so that the laxative can be given 
or withheld, according to circumstances, while the opiate is continued 
more regularly. 



CHOLERA INFANTUM. 637 

When the stage of active inflammation has passed, if there is still loose- 
ness of the bowels, astringents should be employed in connection with the 
opiate. The tincture of catechu or kino may be given with an equal quan- 
tity of paregoric. The subnitrate of bismuth in doses of from five to ten 
grains in combination with Dover's powder or other opiate will also be 
found useful. 

Acetate of lead with opium, so much used in adult cases, is equally 
serviceable in children. One grain may be given to a child of five years 
with one-third of a grain of opium. Injections properly administered aid 
in controlling the inflammation. Those containing opium are especially 
serviceable in relieving the tenesmus of dysentery. When the stomach is 
irritable, or when it is desired to use a medicine like tannic acid, which is 
unpleasant to the taste, it is often best to administer it in the form of en- 
emata or suppositories. 

Local treatment is highly important in the enteritis and colitis of child- 
hood. Leeches in the commencement of the inflammation have a good 
efiect in moderating its intensity. If the disease is secondary, or there is 
scrofula or a state of feebleness, depletion is coutraindicated. 

Apart from leeching, the local treatment should consist in the use of 
emollient applications covered with oil-silk, and made sufiiciently irritat- 
ing by mustard or otherwise to cause constant redness. 

If there are symptoms threatening convulsions, a mustard foot-bath 
repeated occasionally will usually tranquillize the nervous system and avert 
the danger. 

The diet should be bland and unirritating. In the first stages of the 
inflammation, rice or barley-water, or arrowroot boiled in water, and sim- 
ilar drinks should constitute the main diet. When the active inflammation 
has abated, and at any period of the disease if thei'e is a tendency to pros- 
tration, more nourishing food should be given. Milk and animal broths 
may then be allowed. In cases which are protracted, or attended with 
symptoms of exhaustion, alcoholic stimulants are required. 



CHAPTEE X. 

CHOLEKA INFANTUM. 

Cholera infantum, or, as it is sometimes called, cholcriform diarrhoea, 
is a disease of the summer months; and with exceptional cases, of the 
cities. It receives the name which designates it from the violence of vis 
symptoms, Avhich closely resemble those in Asiatic cholera. It is, however. 



638 CHOLERA INFANTUM. 

quite distiuct in its nature, occurring independently of the epidemics of 
that disease. 

I have elsewhere stated that, as regards at least this city, the term cholera 
infantum has been so extended as to embrace a large part of the diarrhoeal 
maladies affecting infants in the summer months. Some physicians apply 
it even to mild but protracted cases of ordinary non-inflammatory or in- 
flammatory diarrhoea occurring in the season mentioned. I employ it, 
and it should, in my opinion, only be employed, to designate that form of 
infantile diarrhoea in which there are frequent watery stools, accompanied 
by vomiting, great elevation of temperature, and rapid and great emacia- 
tion. 

The number of deaths from cholera infantum reported in our bills of 
mortality is so large, while the number from the same disease embraced in 
the death statistics of European cities is so small comparatively, that some 
have been led to believe that this malady is much more prevalent and 
fatal in this country than in Europe, whereas, were these terms employed 
in all places to designate precisely the same disease, probably no great 
difference would be found in the prevalence of cholera infantum on the 
two sides of the Atlantic. 

Causes. — It has been stated that cholera infantum prevails mainly in 
the cities and in the summer months. Cases occur from the month of May 
to October. Its maximum frequency and severity correspond with the 
degree of heat, and it is therefore most prevalent in the mouths of July 
and August. One of the chief causes of this disease is, doubtless, residence 
in an atmosphere loaded with noxious vapors, especially gases arising from 
animal and vegetable decomposition, or an atmosphere rendered impure 
by overcrowding and by personal and domiciliary uucleanliness. It is, 
therefore, much more common in tenement houses and parts of the city 
occupied by the poor than in cleaner and less crowded streets and apart- 
ments. 

Summer heat and the anti-hygienic conditions to which it gives rise in 
the cities, sometimes appear to be sufiicient in themselves to develop 
cholera infantum ; at least it occurs without other obvious cause. In other, 
and probably the majority of cases, another cause co-operates, namely, the 
use of improper food. Atmospheric heat and its depressing influences are 
then predisposing causes, while the use of indigestible or irritating food is 
the exciting cause. Infants upon whom both causes are operative are most 
liable to cholera infantum in its severe form. Hence bottle-fed infants of 
the city are especially liable to it, and infants whose food is carelessly and 
improperly prepared. Often in the hot months, acid and indigestible 
fruits, as currants, heedlessly given to an infant, occasion the attack. 

Cholera infantum occurs commonly under the age of two years. It is 
s* frequent during the period of first dentition, that some writers consider 
dentition a cause. At this period, however, as has been stated elsewhere, 



SYMPTOMS. 639 

there is great functional activity, and rapid development of the intestinal 
follicles, and the peculiar liability to cholera infantum at this age should 
be attributed to this cause rather than to dentition. 

Symptoms. — Cholera infantum sometimes commences abruptly, the 
previous health having been good. In other cases it is preceded by a pre- 
monitory stage, that of diarrhoea. The stools are thinner than natural, 
and somewhat more frequent, but not such as to excite alarm. Suddenly 
the evacuations become more frequent and watery, and the parents are 
surprised and frightened by the rapid sinking and real danger of the in- 
fant. Occasionally this antecedent diarrhoea has continued several weeks, 
attended with emaciation and associated with intestinal inflammation. 

This disease is characterized by the discharge of thin stools, designated 
by some watery, by others serous. The first evacuations, unless there has 
been previous diarrhoea, contain considerable fsecal matter. They are so 
thin as to soak into the diaper like the urine, and in some cases they 
scarcely produce more of a stain than does this secretion. The odor is 
peculiar, not faecal, but musty and ofl^ensive ; occasionally the stools are 
almost odorless. Commencing simultaneously with the watery evacuations, 
or soon after, is another symptom, namely, irritability of the stomach, 
which increases greatly the prostration and danger. Whatever is swal- 
lowed by the infant is rejected immediately, or after a few minutes, or 
there may be retching wdthout yomiting. The appetite is lost, and the 
thirst is intense. Cold water, especially, is taken with avidity, and if the 
infant nurses, it eagerly seizes the breast, in order to relieve the thirst. 
The tongue is moist at first, and clean or covered with a light fur. The 
pulse is accelerated, while the respiration is either natural or somewhat 
increased in frequency; the surface is warm, but its temperature is speedily 
reduced. There is no disease of infancy in which the temperature of the 
blood is so high. In ordinary cases the thermometer introduced into the 
rectum rises above 105°, and I have seen it indicate 1072°. There is no 
abdominal tenderness, and no evidence of pain. The infant is often rest- 
less at first, but its restlessness is due to thirst, or that unpleasant sensation 
which the sick experience when the vital pow'ers are rapidly reduced. The 
urine is scanty in proportion to the gravity of the attack. 

The loss of strength and the emaciation are more rapid than in any 
other diarrhoeal malady, except Asiatic cholera, and the most severe form 
of cholera morbus. The parents scarcely recognize in the changed and 
melancholy aspect of the infant any resemblance to the features which it 
exhibited a day or two before. The eyes are sunken, the eyelids and lips 
are permanently open from the feeble contractile power of the muscles 
which close them, while the loss of the fluids from the tissues and the 
emaciation are such that the bony angles become more prominent, and 
the skin in places lies in folds. 

As the disease approaches a fatal termination, which often occurs in two 



640 CHOLERA INFANTUM. 

or three days, the infant remains quiet, not disturbed even by the flies 
which alight upon its face. The limbs and cheeks become cool; the .eyes 
bleared, pupils contracted, and the urine scanty or suppressed. As death 
draws near the respiration becomes accelerated from the pulmonary con- 
gestion consequent on the feeble contractile power of the heart, the pulse 
becomes more and more feeble, the surface has a clammy coldness, and 
stupor results, which becomes more and more profound, and from which it 
is impossible to ai'ouse the infant. 

In the most favorable cases cholera infantum is checked before the oc- 
currence of these fatal symptoms. And often even in cases which are ulti- 
mately fatal, there is not such a speedy termination of the malady. The 
choleriform diarrhoea abates, and the case becomes one of ordinary entero- 
colitis as described in the foregoing pages. 

Anatomical Characters. — Rilliet and Barthez, who of foreign writers 
treat of this disease at greatest length, describe it under the name of gastro- 
intestinal choleriform catarrh. " The perusal," they remark, " of the ana- 
tomico-pathological description, and especially the study of the facts, show 
that the gastro-intestinal tube in subjects who succumb to this disease may 
be in four different states : (a), either the stomach is softened without any 
lesion of the digestive tube ; (6), or the stomach is softened at the same 
time that the riiucous membrane of the intestine, and especially its follicu- 
lar apparatus is diseased ; (c), or the stomach is healthy whilst the follicu- 
lar apparatus, or the mucous membrane, is diseased ; (d), or, finally, the 
gastro-intestinal tube is not the seat of any lesion aj)preciable to our senses 
in the present state of our knowledge, or it presents lesions so insignificant 
that they are not sufficient to explain the gravity of the symptoms. 

" So far the disease resembles all the catarrhs, but what is special is the 
abundance of the serous secretion, and the disturbance of the great sympa- 
thetic nerve. 

"The serous secretion, which appears to be produced by a perspiration 
(analogous to that of the respiratory passages and of the skin) rather than 
by a follicular secretion, shows, perhaps, that the elimination of substances 
is effected by other organs than the follicles ; perhaps, also, we ought to see 
a proof that the materials to eliminate are not the same as in simple catarrh. 
Upon all these points we are constrained to remain in doubt. We content 
ourselves with pointing out the fact." 

American writers divide cholera infantum into three stages, the first 
characterized by turgescence of the intestinal follicles, with more or less 
softening of the raucous membrane. In the second stage the mucous mem- 
brane of the intestines is vascular in patches and streaks, and somewhat 
thickened and softened, while the solitary glands and patches of Peyer 
present an inflammatory hyperpemia, and occasionally certain of them are 
ulcerated. In the third stage the brain is involved. The cranial sinuses, 
veins, and capillaries of the brain are congested, and there is transudation 



ANATOMICAL CHARACTERS. 641 

of serum upon the surface of the brain or in the ventricles. The following 
observations show the character of these lesions : 

On the 1st of August, 1861, 1 made an autojDsy of an infant sixteen months 
old, who died of cholera infantum, with a sickness of less than one day. 
The examination was made thirty hours after death. Nothing unusual was 
observed in the brain, except, perhaps, a little more than the ordinary in- 
jection of vessels at the vertex; no disease of stomach and intestines ex- 
cept enlargement of the patches of Peyer as well as the solitary glands ; 
mucous membrane pale. In this and the following cases there was appar- 
ently slight softening of the intestinal mucous membrane; but whether it 
■was pathological or cadaveric is uncertain, as the weather was very warm. 
The liver seemed healthy. Examined by the microscope, it was found to 
contain about the normal amount of oil-globules. 

The second case was that of an infant seven months old, wet-nursed, who 
died July 26th, 1862, after a sickness also of about one day. He was pre- 
viously emaciated, but without any definite ailment. The post-mortem 
examination was made on the 28th. The brain was somewhat softer than 
natural, but was otherwise healthy. There was no abnormal vascularity 
of the membranes of the brain, and no serous effusion within the cranium. 
The mucous membrane of the intestines was of normal appearance through- 
out, unless somewhat thickened and softened ; the solitary glands of the 
colon were enlarged. The patches of Peyer were not distinct. 

At the New York Protestant Episcopal Orphan Asylum, an infant twenty 
months old, previously healthy, was seized with cholera infantum on the 
25th of June, 1864. The alvine evacuations, as is usual in this disease, 
were frequent and watery, and attended by obstinate vomiting. Death oc- 
curred in slight spasms, in thirty-six hours. The exciting cause was ap- 
parently the use of a few currants, which were eaten in a cake the day be- 
fore, some of which fruit was contained in the first evacuations. The brain 
was not examined. The only pathological changes which were observed 
in the stomach and intestines were slight vascular patches in the small in- 
testines, and an unusual prominence of the solitary glands in the colon. 
These glands resembled small beads imbedded in the mucous membrane. 
The lungs in the above cases were healthy, excepting hypostatic conges- 
tion. 

Since the dates of these autopsies, I have made others in cases which 
terminated fatally after a brief duration, and have uniformly found similar 
lesions, namely, the gastro-iutestinal surface either without vascularity or 
scantily vascular in streaks or patches, sometimes presenting a whitish or 
soggy appearance, and somewhat softened, while the solitary glands were 
enlarged so as to be prominent upon the surface. In cases which continue 
longer, evident inflammatory lesions soon appear, which are identical with 
those already described in the article which relates to intestinal inflam- 
mation. 

41 



642 CHOLERA INFANTUM. 

Nature. — It was formerly my opinion that cholera infantum is 
tially non-inflammatory, but that it soon became inflammatory if not 
checked. Careful observations of its symptoms and lesions have since 
convinced me that it is the most violent inflammation to which infants are 
liable in our climate. There is no other infantile malady in which there 
is uniformly so high a temperature, and under which patients sink more 
rapidly. The alviue discharges to which the rapid prostration is largely 
due, probably consist in part of intestinal secretions, and in part of serum 
which has transuded from the capillaries of the intestines. It is well 
known to pathologists, that in inflammation of mucous surfaces of short 
duration, the redness is apt to disappear in the cadaver. 

The opinion has been expressed by certain observers that cholera in- 
fantum is identical with thermic fever or sunstroke. There is, indeed, a 
resemblance as regards certain important symptoms. In cholera infantum 
the temperature is from 105° to 108° ; in sunstroke it is also very high, 
often rising above 108°. Great heat of head, contracted pupils, thin 
fsecal evacuations, embarrassed respiration, scanty urine, . and cerebral 
symptoms are common towards the close of cholera infantum, and they 
are the prominent symptoms in sunstroke. Nevertheless, I cannot accept 
the theory which regards these maladies as identical, and which removes 
cholera infantum from the list of intestinal diseases. In cholera infantum 
the gastro-intestinal symptoms always take the precedence, and are, except 
in advanced cases, always more prominent than other symptoms. It does 
not commence as by a stroke like coup de soleil, but it comes on more 
gradually though rapidly, and it often supervenes upon a diarrhoea or 
some error of diet. In the commencement of cholera infantum the infant 
is not apt to be drowsy, and it is often wide awake and restless from the 
thirst. Contrast this with the alarming stupor of sunstroke. Sunstroke 
only occurs during the hours of excessive heat, but cholera infantum may 
occur at any hour, or in any day during the hot weather, provided that 
there is suflicient dietetic cause. Again, intestinal inflammation is not 
common in sunstroke, while it is the common, or as I believe the essential, 
lesion of cholera infantum. These facts show, in my opinion, that the 
two maladies are essentially and entirely distinct. Nevertheless, cases of 
apparent sunstroke sometimes occur in the infant, and if the bowels are at 
the same time relaxed the disease is apt to be regarded as cholera infantum, 
and if fatal is usually reported as such to the health authorities. Such cases 
I have occasionally observed, or they have been reported to me, although 
they are not common. 

With the exception of the organs oF digestion, no uniform lesion is ob- 
served in any of the viscera, unless such as is due to change in the quantity 
and fluidity of the blood, and in its circulation. Writers describe an anaemic 
appearance of the thoracic and abdominal viscera, and occasional passive 
congestion of the cerebral vessels. The cerebral symptoms often present 



DIAGNOSIS PROGlSrOSIS TREATMENT. 643 

towards the close of life in unfavorable eases of cholera infantum may 
arise from that state of the brain known as spurious hydrocephalus, which 
is not attended by any uniform or certain lesion of this organ. As the 
urinary secretion is scanty or suppressed, cerebral symptoms may in cer- 
tain cases be due to uraemia. 

Diagnosis. — This disease is diagnosticated by the symptoms, and es- 
pecially by the frequency and character of the stools. The stools have al- 
ready been described as frequent, often passed with considerable force, 
deficient in fsecal matter, and thin, so as to soak into the diaper almost 
like urine. The vomiting, thirst, rapid sinking, and emaciation serve to 
distinguish cholera infantum from other diarrhoeal maladies. 

When Asiatic cholera is prevalent, the differential diagnosis of the two 
diseases is diflBcult if not impossible. 

Prognosis. — This is one of those diseases in regard to which physicians 
often injure their reputation by not giving sufiicient notice of the danger, 
or even by expressing a favorable opinion, when the case soon after ends 
fatally. A favorable prognosis should seldom be expressed without 
qualification. If the urgent symptoms are relieved, still the disease may 
continue as an ordinary intestinal inflammation, which, in hot weather, 
is formidable and often fatal. If the stools become more consistent and 
less frequent, without the occurrence of cez'ebral symptoms, while the 
limbs are warm and pulse good, we may confidently express the opinion 
that there is no present danger. 

The duration of true cholera infantum is short. It either ends fatally, 
or it begins soon to abate and ceases, or it continues as an entero-colitis. 
Death may occur, in twenty-four or forty-eight hours, in a state of collapse, 
from the frequency of the stools, or not till after three or four days. In 
general, if the patient is not cured in three or four days, and is not fatal, 
the case becomes one of severe ordinary entero-colitis. 

Treatment. — Cholera infantum requires beyond most other diseases, 
the employment of proper remedial measures, from the earliest possible 
moment, since the infant rapidly sinks, unless the evacuations from the 
bowels are arrested, or are rendered less frequent and watery. Regardiug 
the disease as a violent intestinal inflammation, we have no difficulty in 
determining the therapeutic indications. Those already recommended in 
our article relating to intestinal inflammation, are indicated, and to the 
full extent which the infant will bear, without causing too much stupor. 
An infant between the ages of eight and twelve months, should take one 
teaspoonful of the following mixture every two or three hours, till the 
vomiting and diarrhoea are controlled: 

R. Tinct. opii, gtt. xvj. 

Spts. amnion, urouiat., gss.-j. 
Bismuth ?ubiiitrat., ,:^ij. 
Syr. simplex., 
Aqiue, aa gj. Misce. 



644 CHOLERA INFANTUM. 

An infant of six months can take one4ialf the dose, and one of three or 
four months, one-third or one-fourth the dose. Instead of tiiis, one of the 
equivalent mixtures which are recommended for the treatment of intes- 
tinal inflammation, may be given. If cerebral symptoms apjiear, as rolling 
the head, drowsiness, etc., I usually write the prescription without the 
opiate, and it may then be given more frequently if the case require it, 
while the opiate prescribed alone is given more guardedly and at longer 
intervals. 

There is danger in this disease of the sudden supervention of stupor, 
amounting even to coma and ending fatally. In these cases the stools are 
generally suddenly checked, and the opiate might aid in producing this 
result. In a few instances which I can recall to mind, where death occurred 
in this way, the friends believed that the melancholy result was hastened 
by the medicine. If the evacuations are partially checked and there are 
signs of stupor, the opiate should either be omitted or given less frequently. 
Explicit and positive directions to this effect should be given. Eligible 
preparations of opium for this disease are paregoric, tincture of opium, 
pulv. cretse comp. c opio, and, if there is no irritability of stomach, Dover's 
powder. 

Certain writers recommend the employment of a purgative as prelimi- 
nary treatment, in order to remove any irritating substance from the in- 
testines. But delay in the use of remedies to check the evacuations involves 
too much risk. When the urgent symptoms are somewhat controlled, a 
moderate dose of castor oil may be prescribed if there is reason to suspect 
that there is any irritating substance in the intestines. 

By this mode of treatment the stools are generally in a few hours ren- 
dered less frequent and more consistent. 

There are physicians who believe that calomel in small and repeated 
doses has a beneficial effect in choleriform diarrhoea, but those who use it 
employ it in combination with opium, and it is probable that the good 
effect observed is mainly due to the latter remedy. From the anatomi- 
cal characters of cholera infantum there is apparently no indication for 
a medicine that affects the function of the liver, and there is no evidence 
that calomel exerts any good effect on the follicular apparatus of the in- 
testines, which, so far as we can localize the disease, seems to be most in 
fault of any part of the digestive apparatus. On theoretical grounds, 
therefore, I should oppose the employment of this agent, and my observa- 
tions of its effects have been such that I entirely discard its use while we 
have other safe and efficient remedies to meet every indication. 

Ordinarily, as the diarrhoea is relieved, the vomiting ceases. The rem- 
edies employed for the former are also curative of the latter ; still the 
vomiting, if frequent and obstinate, sometimes does require special treat- 
ment, and there are no better anti-emetic mixtures than those recom- 
mended in our remarks on the treatment of intestinal inflammation. In 



INTESTINAL, WORMS. 645 

robust infants, at the commencement of the attack, small pieces of ice 
taken in the mouth aid in diminishing the irritability of stomach. Mus- 
tard should also be applied to the epigastrium. 

In most cases alcoholic stimulants are required. The best of these is 
Bourbon whisky or brandy, which should be used from an early period of 
the disease. Aside from its sustaining the vital powers, it aids also in re- 
lieving the irritability of stomach. 

The diet in cholera infantum should be simple but nutritious. That 
recommended for intestinal inflammation is proper for infants with this 
maladv. 



CHAPTER XL 

INTESTINAL WORMS. 

The belief has been prevalent in the profession, and is now in the com- 
munity, that the presence of worms in the intestines constitutes a frequent 
disease in early life. As the pathology of infancy and childhood, and 
especially the means of diagnosticating diseases, are better understood, 
this idea is gradually abandoned by the profession. Still, intestinal 
worms must be considered an occasional cause of serious derangement or 
even disease, and of death also. 

Worms, indeed, may exist in the intestines without any appreciable 
deviation in the individual from a state of health. Ordinarily, however, 
they in time give rise to symptoms so as to require the use of remedies for 
their expulsion. 

There are five kinds of worms whose habitat is the human intestines, 
namely, the ascaris lumbricoides, ascaris vermicularis, or, as "it is some- 
times called, the oxyuris vermicularis, the trichocephalus disjDar, and two 
species of trenia. The ascaris lumbricoides, when matured, measures 
from five inches to about a foot in length. Young ones are sometimes 
expelled not more than two inches in length. The color is a reddish- 
brown, with a shade of yellow. The dead worm has a paler color. The 
females are in numerical excess of the males, and their size is also greater. 
The worm in shape resembles the common earthworm, from which it de- 
rives the name lumbricus. It is, however, more pointed at both extrem- 
ities than the earthworm, and the color is a paler red. The tail of the 
male worm is curved, while that of the female is straight. The mouth is 
triangular, and is surrounded by three tubercles. 

The ascaris lumbricoides resides usually in the small intestines. It oc- 
casionally enters the stomach, from which it is vomited, or it crawls up 



G-i6 INTESTINAL WORMS. 

the oesophagus into the fauces, from which it is soon removed by the 
efforts of the individuah Cases are on record, one of which Andral wit- 
nessed, in whicli the worm entered the larynx, producing suffocation and 
speedy death. M. Tounelle also witnessed such a case. A child, nine 
years old, was suddenly seized with great difficulty of respiration and 
pain in the upper part of the chest. A careful examination of the thorax 
gave a negative result. Death occurred in from twelve to fifteen hours, 
and at the post-mortem examination a lumbricus was found filling the 
cavity of the larynx. M. Blandin, also, witnessed a case, when interne 
of the Hopital des Enfants. An infant was suffocated by one of these 
worms, which had penetrated as far as the right bronchus. Very rarely 
they crawl from the fauces into the nasal passages. This worm is so 
strong and active that there is no recess or reflexion of the mucous mem- 
brane of the digestive apparatus which it could possibly penetrate, in 
which it has not been found. It has been discovered in the appendix 
vermiformis, in the pancreatic duct, in the common bile-duct, and even in 
the gall-bladder. The number of these worms found in the intestines is 
very various. There may be only one, or the number may be almost in- 
credibly large. 

Thus, Barrier relates the case of an infant thirty months old, who died 
in Hopital Necker. It was believed to be tubercular. Numerous tumors, 
which could be felt in the abdomen, were supposed to be tubercular masses. 
On making the post-mortem examination, the mesenteric glands were 
found healthy, but the intestines throughout their entire extent were filled 
with lumbrici. The masses which, during life, were believed to be tuber- 
cular glands, were found to consist of worms. The coecum, especially, was 
greatly distended by them. The intertwining or collection in balls of 
these worms constitutes, indeed, one of the chief dangers, as it renders 
them so much the more difficult of expulsion. 

The round worm, as this worm is commonly called, possesses no organs 
of penetration, still, if the intestine is weakened by disease, especially by 
ulceration, it may, by pressure with its head, force an opening through 
wiiich it escapes into the cavity of the abdomen, causing peritonitis and 
death. This worm is often found, whether single or in masses, surrounded 
with mucus, which serves as a partial protection to the intestines. 

The portion of the mucous membrane in contact with lumbrici is often 
found inflamed, either from movements of the worm, or from pressure of a 
mass of worms, or even of a single worm in a confined position, as the ap- 
pendix vermiformis. This inflammation, continuing and increasing, may 
end in ulceration, and thus a weakened spot be produced, which may be 
ruptured by simple pressure of the mouth of the worm. In this way are, 
probably, to be explained those apparent cases of perforation, which have 
led some observers to believe that lumbrici had actually the power of 
penetrating the healthy coats of the intestines. 



ASCAEIS LUMBRICOIDES. 647 

M. Guersant describes a case in which the appendix vermiformis was 
found with an opening through which twohnnbrici had partly passed into 
the abdominal cavity. The effect of their impaction in this narrow cul- 
de-sac was much like that of a bean or a seed lodged in the same situation. 

Lumbrici are sometimes found in a most remarkable location, namely, 
in little abscesses, external to the intestines, situated generally in the ab- 
dominal walls. These, after a time, in certain cases, open externally, dis- 
charging pus, one or more worms, and perhaps a little excrementitious 
matter. They result from an opening in the intestine, through which the 
worm has passed, producing circumscribed inflammation and an 
and the intestine, now relieved of the irritant, heals before the al 
reaches the surface. 

The mucous membrane in contact with the worm sometimes presents the 
natural appearance ; in other cases, it is red, being evidently inflamed. 

The ascaris vermicularis, or oxyuris vermicularis, or, as it is termed in 
the vernacular, the threadworm, is also frequent in childhood, and is the 
cause sometimes of much suffering, though generally of less dangerous 
symptoms than the round worm. Its habitat is the large intestine, com- 
monly the rectum. Bremser states that he found it even in the coecum. 
This worm resembles pieces of white thread, and hence its common name. 
The female is larger than the male, measuring about half an inch in length, 
while the length of the male is not more than two or three lines, and it is 
proportionately more slender. It exists often in vast numbers in the rec- 
tum, from which it is expelled with the excrementitious matter. The head 
of the worm is blunt, and is furnished with a transparent vesicle. The 
tail is very slender, terminating in a spiral in the male, while it is straight 
in the female. These worms multiply rapidly, and they move actively 
their anterior extremity. In girls they sometimes enter the vagina, pro- 
ducing a leucoi-rhoeal discharge. 

The trichocephalus dispar, or the long thi'eadworm, is also found in the 
large intestine, but oftener in the caput coli or ascending colon than else- 
where. It measures in length one and a half inches, sometimes even two 
inches. The anterior two-thirds are slender, resembling in size and ap- 
pearance a hair, whence its name trichocephalus. The posterior third is 
considerably larger than the anterior, being, like the ascaris vermicularis, 
spiral in the male and straighter in the female. The worm is of a light 
color. Children are less frequently affected with the trichocephalus than 
with the two kinds just described. It rarely, if ever, produces any symp- 
toms or does any appreciable injury. 

The taenia, or tapeworm, is much less frequent than the round or thread- 
worm. There are two recognized species, the ticnia solium and taenia lata. 
These worms have minute heads, which are different in the two species. 
Their bodies consist of white flat segments, which are united in a different 
manner in the two species. These segments near the head are small, as if 



648 INTESTINAL WORMS. 

rudimental, but as the distance from the head increases they enlarge, till 
their full development is attained. They are quadrilateral, having, when 
fully developed, greater length than bi-eadth in the ttenia solium, greater 
breadth than length in the taenia lata. 

The tteuia is an hermaphrodite, each segment containing the reproduc- 
tive organs complete. The oviduct opens in the centre of the flat surface 
in the taenia solium, upon the edge of the segment in the tsenia lata. 

The taenia attains a great length, but its maximum of growth is not as- 
certained, as pieces are generally detached and expelled from time to time 
before the removal of the entire worm. The tsenia lata is supposed to at- 
tain the length of about fifteen feet. The tsenia solium is considerably 
longer. 

The tsenia is rare in early life, but cases now and then occur. I have 
met but one case in this city under the age of five years. Rosen and Brem- 
ser report cases between the ages of six and eleven years, and Hufelaud 
one at the age of six months. Wawruch collected 206 observations of 
tsenia, in 22 of which the age was less than fifteen years ; the youngest 
was a girl of three years. A most remarkable case of tsenia is reported 
in the Gazette Medicale of Paris in 1837. M. Muller was called to treat a 
foster child five days old for slight constipation. The bowels were evacuated 
by the use of rhubarb, manna, and a few grains of salt, and in the excre- 
ment a foot and a half of tsenia were discovered. This worm had evidently 
existed during the foetal life of the infant. 

A similar case was treated by Prof. Skene, in the Long Island Hospital, 
in September, 1871, and reported by Dr. Armor, in the New York Medical 
Journal. The infant was born September 3d, of a hearty Irish servant 
girl. On the 7th it refused to nurse, and was observed to have a mild form 
of tetanus. On the 8th small doses of calomel having been given, followed 
by castor oil, two segments of a tsenia solium were passed from the bowels, 
and on subsequent days ten more segments, after which the tetanus ceased. 
The remedies employed after September 8th were the oil of male fern and 
turpentine. The mother, who had presented no symptoms of tsenia, was 
ordered an emulsion of pumpkin-seeds, which " she faithfully took for 
twenty-four hours, at the end of which she passed over seventy segments 
of tsenia." This case is interesting as thi'owing light on a possible mode of 
the production of tsenia, quite different from the ordinary and recognized 
mode, and also as showing the causative relation of intestinal worms to 
tetanus infantum. 

Causes. — The vermicular disease is much more common in one locality 
than another. Thus, in Paris there are few cases, while in the provinces 
of France and many other parts of Europe it is a common malady. It 
is more common in this city among the children of the poor than those in 
the better walks of life. 

In the same region, with an identity of regimen, pursuits, and habits, it 



CAUSES, 649 

is sometimes common in one season, and rare in another. It is an interest- 
ing fact, also, as showing the influeuce of local causes, which we often can- 
not appreciate, that, in countries where the disease prevails, the relative 
frequency of the different kinds of worms is often different. Thus, in Eng- 
land, Holland, and Germany, the taenia solium i;s common, and the taenia 
lata rare, while the reverse is true of Eussia, Poland, and Switzerland. 

There is often some derangement or disease of the digestive system, 
which is favorable for the growth of intestinal worms. In cases of con- 
tinued indigestion, accompanied by iri'itation or subacute inflammation of 
the mucous surface, with an excessive secretion of mucus, worms are apt 
to be generated, which aggravate the primary affection. Children in the 
last stages of typhoid fever not infrequently pass lumbrici in the evacua- 
tions from the bowels. 

It has long been a common and correct belief that the use of certain kinds 
of food favors the development of worms. Fruits in excess, and food of an 
inferior quality, or but partially cooked, remaining an unusual time unas- 
similated in the intestines, afford a nidus in which worms are very apt to 
appear. The same may be said of saccharine substances, taken in too 
large quantity or too frequently. An excess of food, even of good quality, 
is also a cause, since this gives rise to the predisposing condition of undi- 
gested nutriment in the intestines. The period of childhood is mentioned 
by writers as one of the predisposing causes. Both the round and thread- 
worms occur oftenest in children between the ages of three and ten years, 
but they are not very infrequent at any age between the first year and 
puberty. 

I have witnessed a large number of autopsies of infants in the institu- 
tions of this city, and, although the intestines in a large proportion of them 
were examined, I can recall only one instance in which intestinal worms 
were present when death had occurred in the first year. This immunity 
is, however, in great part attributable to the simple diet of these institu- 
tions. The infrequency of worms in the first year of life is an important 
practical fact. The immunity is greatest, for obvious reasons, in those who 
are nourished entirely or almost entirely at the breast. 

In this city, children of the poor, living in almost total disregard of 
sanitary requirements, are especially liable to worms. This is attributable 
not only to the character of their food, which is often of inferior quality 
and poorly prepared, but also to the filthy and insalubrious state of the 
domiciles and streets in which they reside, and the consequent cachexia. 
One of the older writers remarks that intestinal worms, like confervoid 
growths, thrive best where it is filthy and dark. Though such analogical 
reasoning is not to be accepted, the fact remains of the great liability to 
worms of those children who reside in insalubrious and humid localities 
which are favorable also for cryptogamic vegetation. 



650 INTESTINAL WORMS. 

Symptoms of Lumbrici. — These are in part constitutional or sympa- 
thetic, and in part local, due to the mechanical effect of these entozoa on 
the coats of the intestines. Writers, especially Rilliet and Barthez, have 
described the symptoms supposed to indicate lumbrici with minuteness. 
Those of a constitutional or sympathetic character are the following : 
Features sometimes flushed, sometimes pallid, and sometimes of a leaden 
hue ; lower eyelids swollen, and sometimes surrounded by a blue semi- 
circle; thirst, nausea, or even vomiting; appetite diminished, or entirely 
lost, or, on the other hand, augmented ; breath foul ; papillse of the tongue 
red and projecting ; pulse accelerated and irregular. Rilliet and Barthez 
state that they observed this irregularity in a boy three years old, at the 
time he was passing a large number of lumbrici. The irregularity after- 
wards disappeared. Acceleration of the pulse is one of the most common 
symptoms of these worms. The popular idea of " worm fever " has indeed 
a foundation in fact. This fever is often remittent and mild, but occasion- 
ally it is continuous and of a high grade. 

The symptoms pertaining to the nervous system are important. In mild 
cases they may be absent, as when there are few lumbrici, and the child is 
robust, and over the age of five years, but in severe cases more or fewer of 
these symptoms are commonly present. They are dilatation of the pupils, es- 
pecially inequality of dilatation, to which Munro attached diagnostic value; 
strabismus, twitching of the muscles, clonic convulsions, somnolence, head- 
ache, neuralgic pains, delirium. Rarely chorea, deafness, and paralysis, 
it is believed, may result. (M. Bouchut, Gaz. des Hopitaux, 1867.) In 
the Amer. Jour, of Med. ScL, for July, 1869, Dr. Leedom, of Montgomery 
County, Pa., relates the case of a boy of seven years, who had night-blind- 
ness due to a large number of lumbrici in the intestines. By the employ- 
ment of pinkroot and calomel these were expelled, and the blindness 
ceased. Hyperesthesia of the abdominal surface was present in a case 
which I attended, and which subsided as soon as the lumbrici were ex- 
pelled. Grinding the teeth in sleep, and picking the nostrils, are symp- 
toms to which families attach great value. Observations, however, show 
that, though sometimes due to worms, they more frequently have another 
cause. 

The local symptoms or disorders, in other words those having a 
mechanical origin, are colicky pains, experienced chiefly in the umbilical 
region; in some patients, simple non-inflamraatory diarrhoea ; in others, 
enteritis ; and in others still, colitis ; stools sometimes natural ; in other 
cases, liquid but fsecal ; and in others still, muco-sanguineous ; flatulence, 
M. Davaine, at a recent period, made the important discovery that the 
faeces of patients affected with worms contain the ova of the particular 
species present, in large numbers. The ovum of the lumbricus is oval and 
granular, while that of the trichocephalus is spherical, with a small projec- 
tion at each end, those of the threadworm oval and irregular, and those of 



SYMPTOMS. 651 

the tsenia round. These ova can be seen through a lens magnifying 150 
diameters. 

In exceptional cases, there are local symptoms due to the presence of 
worms in unusual situations, such as a crawling sensation in the oesophagus ; 
a sense of constriction in this tube or the pharynx ; nausea and vomiting ; 
a cough, especially if the worm has crawled to the upper part of the 
oesophagus ; rarely the most urgent dyspnoea, and probable suffocation, if 
a lumbricus has entered the larynx. 

The enteritis and colitis, to which these worms sometimes give rise, is 
ordinarily mild, but in i^are instances ulceration occurs, which may be 
attended by profuse and even fatal hseraorrhage. Occasionally very pain- 
ful and dangerous constipation results from an accumulation of worms, in 
a ball or mass, too large to be expelled, unless with much delay and suffer- 
ing, preventing the passage of fsecal matter, and producing severe abdominal 
pains. The symptoms in these cases resemble closely those of intussuscep- 
tion. A marked example of constipation produced in this way occurred 
in a family with whom I am acquainted, and who then resided in the in- 
terior of this State. A little girl of three or four years was suddenly 
affected with obstinate constipation. The physicians prescribed active 
purgatives, calomel among others, and finally croton oil, and various in- 
jections, without relief. There was great pain, with distension of the ab- 
domen, and death seemed inevitable, when, after the lapse of several days, 
a free evacuation occurred, and in the stool was a mass of woi'ms firmly 
intertwined. 

Children often have lumbrici without any appreciable impairment of 
the general health, but their presence may intensify the symptoms of 
intercurrent diseases, and greatly increase the danger. Thus, I recollect 
two children of three and three and a half years, with pneumonitis, who, 
at the same time, had lumbrici, one passing in the course of a few days 
thirty and the other twelve of these entozoa. Both presented well-marked 
physical signs of pneumonitis, and, though they recovered, the febrile move- 
ment and nervous symptoms were apparently aggravated by the intestinal 
affection. One had convulsions in the commencement of the inflammation, 
followed by profound stupor and amaurosis, lasting two or three days. 

Often the symptoms due to lumbrici coexist with those of a protracted 
and distinct intestinal disease. Thus, as we have seen, the intestinal secre- 
tions of typhoid fever and of chronic diarrhoeal maladies afford a nidus 
for the growth of worms, and accordiugly, at an advanced stage of these 
diseases, lumbrici are common. 

The symptoms produced by the ascaris vermicularis are somewhat differ- 
ent. These worms do not usually cause the fever, disturbed digestion, the 
colicky pains, or the dangerous nervous symptoms which arise from the 
presence of lumbrici. Nor do they, like lumbrici, endanger life by crawl- 



652 INTESTINAL WORMS. 

ing into unusual situations. Convulsions have been attributed to them, 
but such a result is exceptional, if, indeed, the cause was rightly assigned. 

The most common symptom produced by the ascaris vermicularis is an 
intense itching of the anus. This is most intense at night when the child 
is in bed. It is sometimes absent during the day, but it returns so regu- 
larly at night, from the increased activity of the worm, that it has even 
been mistaken for a periodical nervous affection, and treated as such by 
quinine. So eminent a physician as M. Cruveilhier confesses that he has 
made this mistake. The itching sometimes leads to onanism, and in the 
female child the ascaris occasionally passes from the rectum to the vagina, 
where it gives rise to leucorrhoea. 

The trichocephalus dispar and the taenia are so rare in childhood, that 
few physicians ever meet a case. The trichocephalus is said by some to 
produce no symptoms. The symptoms due to ttenia in children are not 
different from those in the adult. 

Diagnosis. — Bremser long since made the i-emark, and it has been re- 
peated by most writers on diseases of children, that there is no sign or 
symptom which affords positive proof of the presence of intestinal worms, 
except the expulsion of one or more. Late microscopic investigations have 
revealed, however, a pathognomonic sign, namely the presence of ova in 
the f?eces, which indicate not only the nature of the disease, but the species 
of the worm. 

The symptoms and disorders produced by lumbrici may all occur from 
other causes. Still, if several of them are present, and a careful examina- 
tion discloses no other cause, the presence of worms should be suspected, 
provided the child is over the age of two years. The microscope may then 
be used for diagnosis. A little tentative treatment, entirely safe to the 
child, will also determine whether the suspicion is correct. One or two 
doses of medicine, administered under such circumstances, like the sur- 
geon's exploring needle, may reveal the nature of the disease, and indicate 
the means of cure. 

In case of the ascaris vermicularis, the itching directs attention to the 
anus as the place of the disease, and here the offending entozoa may often 
be discovered by the eye. 

Prognosis. — Intestinal worms produce a fatal result in only a small 
proportion of cases. The ascaris vermicularis never proves fatal, unless 
in rare instances, through convulsions. The manner in which death may 
be produced by lumbrici has already been pointed out. 

In general, when the nature of the disease is ascertained, the worms are 
readily expelled by treatment, and the patient restored to health. If then 
there is no complicating disease, the prognosis is good. 

Treatment. — Much injury has been done to children by the use of 
anthelmintics occasionally employed by physicians, but oftener by parents 
before the physician is called. Medicines of this kind are usually irritants, 



TREATMENT. 653 

and, in many of those diseases which simulate the verminous affection, but 
are distinct from it, there is already an irritated if not an inflamed state 
of the intestinal mucous surface. 

Vermifuges administered under such circumstances obviously do harm, 
and in all acute diseases in which they are not required, even if their action 
is harmless, their employment is to be regretted, since it consumes time 
which is very precious. It is thus that many lives are lost by the use of 
anthelmintic nostrums, which are extensively advertised and which com- 
mand a ready sale, since the belief in the presence of worms as a frequent 
cause of disease pervades all classes of the community. 

A safe rule, followed by many physicians, and it would be much better 
if it were general, is not to give anthelmintics unless the child has passed 
one or ' more worms, or their ova are found in the faeces, and not then if 
the- symptoms seem to be referable to a coexisting disease. In doubtful 
cases in which the symptoms resemble those of worms, a purgative dose 
of calomel or calomel and rhubarb may be employed. It will generally 
bring away one or more lumbrici or a mass of ascaris vermicularis, if either 
species of entozoa is present. This purgative may be safely employed if 
there is no previous diarrhoea or debility. If after one or two doses and 
a free pui'gation no worms are passed, anthelmintic remedies should not be 
given, for it is almost certain that no worms exist. 

A large number of medicines have, or have had, a reputation as anthel- 
mintics. Santonin, the active principle of the European wormseed, is one 
of the best, and is much employed in this country and in Europe. It is 
nearly tasteless ; it may be given in powder, spread on bread with the butter. 
It is kept in shops in one or two-grain lozenges, with and without calomel. 
It has the advantage of easy administration, and is destructive to both the 
round and threadworm. M. Bouchut considers it preferable to all other 
remedies in the treatment of the round worm. " To childi'en two years 
of age he administers it in doses of ten centigrammes (2.30 grains), and 
in patients above this age the quantity is increased by five centigrammes 
(1.15 grains) for every additional year." He gives in addition occasional 
doses of calomel or castor oil. In this country santonin is usually admin- 
istered in one to three-grain doses, two or thi'ee times daily, with an occa- 
sional purgative. The purgative is required to aid not only in the expul- 
sion of the worm, but also of the ova. In overdoses santonin causes 
vomiting, diarrhoea, and altered vision, so that objects appear yellow, but 
in medicinal doses it produces no unpleasant consequences. Other med- 
icines are preferable if there are symptoms of enteritis. For many years 
the anthelmintic most employed in this country was the pinkroot, the root 
of the Spigelia marilandica, an indigenous plant. It was not only pre- 
scribed by physicians, but employed by families as a domestic remedy. 
It is apt to cause, if the dose is large, cerebral symptoms, as vertigo, 
dimness of sight, spasm of the facial muscles, stupor, and even convulsions. 



654 INTESTINAL WORMS. 

These effects less frequently occur if the pinkroot is given with a purga- 
tive, and it has been customary to administer it in combination with senna 
in an infusion. A half ounce of spigelia Avith an equal quantity of senna 
is macerated for two hours in a pint of boiling water, and then strained. 
For a child two or three years old the dose is half an ounce to one ounce. 
So popular has this vermifuge been in this country, that probably a ma- 
jority of the native-born adults in the States recollect the nauseating 
doses of pinkroot administered by anxious parents. Pharmacy now pro- 
vides us with the same medicine in a more convenient and acceptable 
form, that of the fluid extracts : 

R. Fluid ext. spigel., f_^j. 

Fluid ext. scnnre, fgss. Misce. 
One teas^poonful to a child from three to five years. 

The ofiiciual fluid extract of spigelia and senna may be given in the 
same dose. Professor Procter recommended the addition of santonin to 
this extract : 

R. Fluid ext. spigel et sennre, f^j. 
Santonin, gr. viij. Misce. 

This is probably the best anthelmintic that can be employed for the 
destruction of the round worm in uncomplicated cases, and it is also very 
useful in treating the ascaris vermicularis. Chenopodium is also a good 
anthelmintic. It is efiicient, and at the same time one of the safest in 
case the mucous membrane is inflamed. If there is abdominal tender- 
ness, with stools too frequent, and thin, or mucous, and tinged with blood, 
I should prefer the chenopodium to most of the other vermifuges. To a 
child of three years five drops of the oil may be given three times daily. 
It may be continued for a longer period than would be safe for most of 
the other vermifuges. Twice a week, during its use, a mild purgative 
should be given, as castor oil, rhubarb, or magnesia, unless the bowels are 
open. It may be given dropped on sugar, or in a mucilaginous mixture. 

Dr. J. F. Meigs says : " I myself rarely gave any other remedy than 
wormseed oil in slight and especially in doubtful cases, unless this has 
already been tried and failed. From my own experience, I believe that 
this remedy is all-sufficient in a large majority of the cases that occur in 
this city, as these are almost always of a mild character, and as it not 
only produces the expulsion of the parasites when they exist, but also 
acts beneficially upon the forms of digestive irritation which simulate so 
closely the symptoms produced by worms. I am persuaded, indeed, that 
of all the cases that have come under my notice, in which it seemed prob- 
able that worms might be present, none were expelled in nearly half, and 
yet the signs of disturbed health have passed away under the use of the 



TREATMENT. 655 

remedy." . . . . " The following is a very good formula for the adminis- 
tration of this remedy : 

R. 01. chenopodii, gtt. Ix vel gj. 
P. g. acacise, ^ij. 
Syrup, simplic, ^^j. 
Aq. cinnamom., gij. Misce. 
" Give a dessertspoonful three times a day for three days, and repeat after sev- 
eral days." 

In cases of protracted intestinal disease attended by an increased and 
vitiated secretion from the mucous surface, a state which often gives rise 
to worms, turpentine is one of the best anthelmintics. In fact, in some 
of these cases there is no good substitute for it. For example, a boy of 
about ten years, attended by myself, October, 1864, had reached or nearly 
reached the fourth week of typhoid fever, when he passed from his bowels 
a large quantity of blood. He Avas previously emaciated and weak, and 
there had been, as is usual in such cases, considerable diarrhoea. The 
haemorrhage was attended with great prostration, from which, however, 
he partially rallied by the use of stimulants. On the following day an 
equally severe hsemorrhage occurred, attended with coldness of the face 
and extremities and great feebleness of pulse, so that death appeared im- 
minent. Turpentine was now administered every six hours, a few lum- 
brici were passed, and the case thenceforth progressed favorably. The 
mechanical effect of the lumbrici on the ulcerated surface of intestine 
had probably given rise to the hsemorrhage. Turpentine may be given 
in doses of from five to ten minims three times daily to a child five years 
old. Sweetened milk or sugar in powder is a good vehicle for it, or it 
may be given in a mucilaginous mixture. 

R. Spts. terebinth, rect., ^ij. 
01. limonis, gtt. v. 
Mucil. gum acac, 
Syr. simplic, aa ^vj. 
Aq. anisi, ^j. Misce. 
Dose, one teaspoonful every six hours. 

The following formula for the employment of this agent is recommended 

by Dr. Condie : 

R. Mucil. gum acac, 5ij. 
Sacch. alb., gx. 
Spir. aether, nitr., _5iij. 
Spir. terebinth, rect., ^iij. 
Magnes. calcinat., 3J- 
Aquto menthaj, gj. Misce. 

It is useless to enumerate the many anthelmintic mixtures which have 
been extolled from time to time. Those mentioned above are the least 
nauseous, and will rarely disappoint the practitioner. One other antidote 



GoG GASTRO-INTESTIXAL HAEMORRHAGE. 

for the rouud worm should be mentioned, as it has been much used and is 
efficient, namely, cowhage. This consists of the bristles which cover the 
pods of the Mucuna j^rwiens, a tropical plant. The pods are dipped in 
plain syrup of the ordinary consistence, and the bristles are scraped off 
with the syrup. When enough of the medicine is added to render the 
syrup of the consistence of thick honey, it is ready for use. The dose is a 
teaspoonful every morning for three days, after which a cathartic should 
be administered. I have never prescribed cowhage, although it is not un- 
frequeutly ordered by physicians, and a popular nostrum consists chiefly 
of it. 

Threadworms require different treatment. The anthelmintics described 
above have less effect on them than on the lumbrici. Still, they may be 
administered for the expulsion of the former, but rather as adjuvants to 
the main treatment. The main treatment should be local, consisting in 
the use of injections, since from the habitat of this worm enemata will or- 
dinarily reach and destroy it. The substances which have been success- 
fully employed as enemata are salt and water, lime-water, a decoction of 
aloes, or a decoction of two cloves of garlic in milk. West recommends 
the injection of six ounces of lime-water and two drachms of tincture ferri 
chloridi. Trousseau uses a solution of the arseuite of soda. 

R. Sodn? arspiiit., o;r. j. 

Aq. destillat., 5xij. M. 
For six euematii, onu or two daily. 

Cold injections are more effectual than warm, and even a daily injec- 
tion of cold water has sometimes been found sufficient to effect a cure with 
proper internal remedies. 

Tlireadworms in the rectum may also be destroyed by ointments con- 
taining mercury, as a drachm of mercurial ointment mixed with oil or 
melted butter, or five grains of calomel with the yolk of an egg. (Bouchut.) 
After the expulsion of the worms patients often require tonic treatment. 
In the treatment of tsenia in children the pumpkin-seed is a safe and effi- 
cient remedy, and is the one now commonly employed. 



CHAPTEE XII. 

GASTRO-INTESTINAL HAEMORRHAGE. 

HiEMORRHAGE from the capillaries is more frequent in infancy than at 
any other period of life, whether in consequence of the irregularity of the 
circulation and frequent congestions in the infant, or the greater delicacy 



GASTRO-INTESTINAL HAEMORRHAGE. 657 

and feebleness of the minute vessels at this age. Hsemorrhage, generally 
capillary, from the gastro-intestinal raucous surface, occurs sufficiently 
often in the child, and especially in the infant, to render it a disease of 
some importance. It is more frequent the younger the individual. 

This hsemorrhage occurs in three distinct pathological states : first, in 
the newborn infant from causes not fully ascertained ; secondly, from a 
pathological state of the blood or the vessels in which it circulates, and 
which is often connected with purpura hsemorrhagica ; thirdly, from a 
local cause. 

First Variety. — In 49 cases, which I have collected from different 
writers, the haemorrhage occurred in 38 under the age of six days, in 5 from 
six to ten days, and in 6 from ten to twenty days. Some authors cite cases 
which occurred at the age of several weeks, but hsemorrhage into the in- 
testines at so late a period cannot be due to any cause operating at birth, 
and it is proper to consider such as examples of one of the other varieties. 

Passive congestion of the gastro-intestinal mucous membrane is not in- 
frequent in the newborn. Billard speaks of twenty-five cases without 
hsemorrhage which he has examined. This anatomical state of the mucous 
membrane of the intestines, whether occurring as part of a general plethora 
or being simply a local affection with no hypersemia of other parts, evi- 
dently requires only a certain increase and hsemorrhage inevitably results. 

The cause of the abnormal congestion of the gastro-intestinal mucous 
membrane, so common in the newborn, has been referred by writers to 
the previous health of the parents, to circumstances attending the birth, 
especially too prompt a ligature of the cord, to irritant matters in the in- 
testines, to external violence, and to the two opposite extremes, namely, a 
plethoric and a feeble state. In my opinion, the chief cause, in many 
cases, is the tardy or incomplete establishment of the respiratory and 
circulatory functions, which gives rise to congestion in the cavities of 
the heart and in the lungs, and, consequently, in the capillaries of the 
systemic system. Evidently, this congestion is most intense in the full- 
blooded. Billard says, of fifteen cases of intestinal hsemorrhage which he 
examined, most of them were remarkable for the plethoric condition of 
their bodies and the general congestion of their integuments. Some, on 
the contrary, were pale and feeble, as is common after abundant haemor- 
rhage. 

In two infants who died soon after birth, and whose bodies I subse- 
quently examined, there was apparently a plethoric state, which rendered 
the fatal result more certain, if it did not, indeed, produce it. In one of 
these, in addition to intense general congestion, meningeal apoplexy had 
occurred, although the birth of the child had been easy. 

It is not difficult to understand in what way too speedy a ligature of the 
cord may be a cause of capillary congestion and hsemorrhage. At the 
moment of birth, the uterus is contracted, the placenta compressed, and, if 

42 



658 GASTEO-INTESTINAL, HEMORRHAGE. 

the cord is now tied, more blood remains in the vessels of the infant than 
if tied a little later. A little later, in consequence of the temporary cessa- 
tion of uterine contractions, and the re-establishment of circulation in the 
infant, blood flows through the cord towards the placenta. The cord thus 
acts as a safety valve to the circulation. Any accoucheur who will take 
pains to witness the effect on the cord of the return of circulation, will ob- 
serve what I have stated. Too speedy a ligature of the cord would not, 
however, be sufficient in the majority of cases to produce that amount of 
plethora which would give rise to intestinal haemorrhage without other co- 
operating causes. 

Tardy or incomplete establishment of respiration and circulation, which 
gives rise to intestinal congestion and hsemorrhage, may be due to disease 
of the heart or lungs, as atelectasis or cyanosis, to feebleness of the infant, 
or to slow and difficult birth. In a large proportion of cases, however, the 
birth is easy. Thus, three of five patients with intestinal hsemorrhage, 
who were treated by M. Gendrin, were born of an easy labor, and the 
same was true of four infants observed by M. Kiwisch. 

The second variety of gastro-intestinal hsemorrhage often occurs as a 
sequel of other and debilitating diseases. I have known it to occur as a 
sequel of measles, small-pox, scarlet fever, and in one case of typhoid fever. 
One of these patients, when apparently the period of danger was passed, 
began to lose blood from nearly all the mucous surfaces, from the nostrils 
and gums, as well as intestines, and the case, which but for the hsemor- 
rhage would doubtless have had a favorable issue, terminated fatally in 
less than a week. 

Patients with this variety of gastro-intestinal hsemorrhage sometimes 
present the maculse of purpura, and commonly their aspect is pallid and 
cachectic. The following was a fatal case of hsemorrhage occurring from 
the ileum, in a mild form of purpura hseraorrhagica: 

Case. — An infant, eight months old, of healthy parentage, nursing, with 
no previous sickness, and fleshy, vomited a small quantity of blood on the 
25th of March, 1865; soon after it passed a stool consisting of almost pure 
blood. On the following day five or six patches of purpura hseraorrhagica 
were observed on the arms and legs. These maculse continued till death. 
There was no more hsematemesis, but the stools, which were from two to 
four daily, consisted largely of blood. Death occurred from exhaustion 
on March 31st. 

Sedio Cadaver. — Head not examined ; thoracic organs healthy, but pale; 
liver fatty ; stomach, upper part of small intestines, and entire colon of 
normal appearance, unless presenting a somewhat lighter color than the 
healthy intestine from deficiency of blood ; mucous membrane in the ileum 
to the extent of several inches, intensely injected without thickening. The 
blood had obviously escaped from this portion of the intestine, and a mod- 
erate amount of this fluid was found in the tube below the point of vascu- 
larity. This case is interesting not only on account of the development of 
purpura hseraorrhagica, but the subsequent melsena in a nursing child, ap- 
parently of healthy parentage, and without previous sickness. 



GASTEO-INTESTINAL H^MOREHAGE. 659 

In our remarks on internal convulsions, the case is related of a scrofu- 
lous infant who, to all appearance in her ordinary health, suddenly be- 
came affected with intestinal h8emorrhage in connection with external and 
internal convulsious. A point of interest in this case was the relation of 
the hsemorrhage to the neurosis. In one of the three cases of intestinal 
hsemorrhage described by West, there were also convulsions. In rare in- 
stances there is an hereditary hsBmorrhagic diathesis to which the haemor- 
rhage is attributable. In the New York Journal of Medicine and Surgery, 
July, 1840, Prof. Swett relates the history of a hsemorrhagic family. 
Seventeen out of eighteen children of this family had died of haemor- 
rhages, and the survivor had had intestinal hsemorrhage with epistaxis. 

In the third variety, among the local causes producing haemorrhage may 
be mentioned ulceration as in typhoid fever, or in severe intestinal in- 
flammation, the mechanical effect of solid substances, lumbrici, invagina- 
tion, obstruction to the portal circulation, polypus of the rectum. Occasion- 
ally at the post-mortem examination of young infants I have found blood 
with mucus in the duodenum and jejunum, these portions of the intestines 
being at the same time intensely congested. In one case of protracted 
entero-colitis occurring in the summer season, I found many small circular 
ulcers in the colon, nearly all containing points of extra vasated blood. Such 
are the principal local causes of haemorrhage from the bowels. Ordinary 
colitis may also be considered a cause, although the amount of blood 
evacuated in this disease is commonly small. 

Of the three forms of intestinal haemorrhage described above, that arising 
from local causes is most frequent, while that occurring from a purpuric 
or haemorrhagic diathesis is least frequent. In rare cases fatal intestinal 
haemorrhage may occur in the newborn, and the blood be retained in the 
intestine, or if passed it may so closely resemble the meconium that its 
true nature is not discovered. M. Bednar relates the following case 
(Krankheiten der Neugehorneii) : " On the eleventh day after birth the 
boy's skin (then of a pale yellow color) diminished in warmth, the impulse 
of the heart became dull and prolonged, the respiratory murmur scarcely 
perceptible. The child lay almost motionless and slumbering. The day 
following the surface could scarcely be kept warm, and the little patient 
had to be aroused to suck. On the twentieth day after birth it died. The 
brain was found to be anaemic, the lungs plethoric, whilst blood was effused 
into the duodenum and stomach." 

Intestinal is more frequent than gastric haemorrhage, and the flow, ex- 
cept when produced by a local cause, is usually from the small intestines. 
The blood, unless it comes from a point near the anus, as the rectum or 
descending colon, is commonly dark, and sometimes partially decomposed, 
emitting an oflensive odor. Admixture of the blood with the intestinal 
secretions prevents coagulation of the fibrin. 

Gastro-intestiual haemorrhage in itself produces few symptoms aside 



660 GASTEO-INTESTINAL H^MOERHAGE. 

from the prostration which atteuds all haemorrhages. The disease with 
which it is associated may give rise to many and severe symptoms. 

Prognosis. — The result in the first and second varieties is much more 
unfavorable than in the third. Many newborn infants affected with 
gastro-intestinal haemorrhage die, but some recover. Billard attended 
fifteen fatal cases. It is probable, however, that death in the first variety 
is often due more to some coexisting lesion, than to the intestinal hi3emor- 
rhage. Meningeal apoplexy, and the incomplete establishment of the 
circulatory and respiratory functions, may both operate as direct causes 
of death in this variety. 

In the second variety, also, a very guarded prognosis should be given ; 
so great a change in the circulatory system as to cause rupture of the 
capillaries, or transudation of blood in the ordinary course of the circula- 
tion, is a serious state. When this haemorrhage occurs as a sequel of the 
eruptive fevers, or in purpura hsemorrhagica, the patient is more apt to 
die than recover. 

In the third form of intestinal hsemorrliage, the result depends on the 
nature of the cause, whether it is susceptible of removal. The majority of 
cases ill this variety recover. 

Treatment. — Billard recommends, as a means of preventing capillary 
congestion and haemorrhage in the newborn, to allow a little blood to 
escape from the umbilical cord before its ligation, if the establishment of 
respiration and circulation is difficult or incomplete. This relieves the 
hyperaemia of the internal organs and facilitates the flow of blood. After 
the commencement of internal haemorrhage and the appearance of bloody 
stools, the same may be done if plethora is indicated by the florid and 
robust appearance of the infant, and the cord is not too much shrivelled. 

The treatment, both therapeutic and regimenal, of intestinal haemorrhage 
should vary according to the age and state of the infant, the profuseness 
of the haemorrhage, and the nature of the cause. Perfect quietude, in the 
recumbent position, is requisite in all severe cases. Derivation to the ex- 
tremities should be procured in the young infant, by heated dry flannel 
or flannel wrung out of hot water; in the older infant, by the same, with 
the addition of mustard. The nursing infant should remain at the breast, 
being allowed, perhaps, in addition to the breast-milk, a little cool barley 
or gum-water. Spoon-fed infants should be given food of the blandest 
quality, in the liquid form and cool. This is the proper diet, whatever the 
age, in the commencement of the haemorrhage. If there are evidences of 
exhaustion, cool beef tea, or essence, and alcoholic stimulants, are necessary. 
It has been advised, in certain forms of intestinal haemorrhage, to apply 
leeches over the abdomen or around the anus. This treatment would, in 
my opinion, rarely be useful, but, on the contrary, in most cases, injurious. 
Haemorrhage from a mucous surface, when once established, will generally 
quickly relieve the local hyperaemia, and leeching, unless very cautiously 



INTUSSUSCEPTION. 661 

employed, would promote the prostration, in which the real danger in this 
disease consists. On the other hand, moderate counter-irritation over the 
ahdomen may be attended with real benefit as a derivative. 

The therapeutic treatment consists mainly in the use of astringents. Of 
the mineral astringents, acetate of lead and nitrate of silver have been used, 
but the liquor ferri subsulphatis is preferable to all other astringents in 
hsemorrhage from the stomach and upper part of the small intestine, but 
it is believed to be decomposed in its passage through the intestine, so that 
it has less astringent or styptic effect in the lower bowel than gallic acid. 
It may be given to a child five years of age, in doses of three or four drops, 
in sweetened water or in mucilage. 

Astringent enemata are sometimes useful. M. Rilliet treated a case 
which recovered with enemata, each containing twelve grains of extract of 
rhatany,a sti'ong decoction of the same astringent being applied externally 
to the abdomen. M. Bouchut recommends " cold water externally to the 
abdomen, internally by the month, or by enemata frequently repeated. 
These enemata should be composed of two or three large spoonfuls only. 
They may be rendered more active with three grains of tannin, or with 
seven grains of the extract of rhatany, or seven grains of catechu, or, lastly, 
with one grain of nitrate of silver. In this latter case, a small glass syringe 
and distilled water must be used, to avoid the premature decomposition of 
the medicine." 

In the haemorrhage occurring in purpura, or after exhausting constitu- 
tional diseases, tonics should be given in addition to astringents. In chronic 
inflammatory disease of the intestinal mucous membrane, attended by a 
vitiated secretion of the follicles, the hsemorrhage may be best treated by 
turpentine. I have elsewhere related two cases of recovery by the use of 
this agent, in one of which (typhoid fever) lumbrici were expelled. 

If the hsemorrhage is due to a local cause, as lumbrici or a rectal polypus, 
the treatment obviously should consist in the removal of this cause. 



CHAPTER XIII. 

INTUSSUSCEPTION. 

Intussusception, or the passage of one portion of intestine into another, 
has long been known as an occasional accident. Hippocrates, though de- 
barred from the study of morbid anatomy, appears to have had a pretty 
clear idea of this lesion, and he suggested a mode of treatment which has 
been employed till the present time. 



662 INTUSSUSCEPTION. 



Intussusception without Symptoms. 



This is not properly a disease. It consists in a displacement without any 
other anatomical change. There is, therefore, no obstruction, inflamma- 
tion, or even congestion present, and no symptoms. This form of invagi- 
nation might ordinarily be reduced by the normal peristaltic and vermicu- 
lar movements of the intestine. 

Invagination of a portion of the small intestine into the part immediately 
below it is often observed at the post-mortem examination of young infants, 
"who had presented no symptoms due to the displacement. The invaginated 
mass is usually from half an inch to two inches in length, and, as a rule, 
this accident is multiple. There may be ten or more distinct intussuscep- 
tions, at distances of a few inches from each other. The simple displace- 
ment is believed to occur ordinarily at or a short time prior to the moment 
of dissolution. It has been supposed to be most frequent in those who 
have died of cerebral or spasmodic diseases, but its occurrence is not un- 
usual in other pathological states. I have often found it at the post-mortem 
examination of infants who have had subacute or chronic entero-colitis. 
Hevin states that he has seen it at the Salpetriere over three hundred times. 
Billard has seen it especially in infants w^ho have been subject to constipa- 
tion. Any irritant, mechanical or other, which disturbs the regular move- 
ments of the intestines, doubtless may produce it. It has been caused in 
the rabbit by irritating the anus. 

It is not improbable that simple intussusception occasionally occurs 
temporarily in children whose health remains good, when the regular 
movements of their intestines are disturbed by irritating ingesta or other 
causes. This form of displacement never takes place in the large intes- 
tine. Its usual seat is the lower part of the jejunum, and upper part of 
the ileum. As it possesses little interest as regards pathology, and none 
whatever as regards symptomatology and therapeutics, it may be ignored 
in our description of intussusception. 

Intussusception with Symptoms. 

Intussusception, or invagination, is one of the most painful and danger- 
ous of human maladies, but fortunately is not very frequent. I possess 
the records of fifty-two cases, from which the principal facts contained in 
this paper are derived. The patients were under the age of twelve years. 
The statistics furnished by these records, therefore, relate to both the 
periods of infancy and childhood. 

Previous Health. — In thirty-four of the fifty-two cases, the state of 
the health previously to the iuvagination was recorded. From the follow- 
ing table it is seen that half, or seventeeen, were previously well, the re- 
maining half suflfering from some disease or derangement : 



INTUSSUSCEPTION WITH SYMPTOMS. 663 



Previous Health. 



Age. Good. Disease or Derangement. 

One year or under, ..... 15 8 

Over one year 2 9 

17 17 

MM. Rilliet and Barthez, whose views in reference to intussusception 
are derived from the examination of the records of twenty-five cases, state 
that the previous health is ordinarily good, and the disease is, therefore, 
primitive. Their remark, according to the above statistics, is seen to be 
correct as regards patients under the age of one year, but incorrect for 
those over that age. 

Most of the seventeen who had previous ill-health had diarrhoea, dysen- 
tery, or constipation, or diarrhoea alternating with constipation. Of those 
otherwise affected, one had threadworms, two obscure abdominal pains, 
one nausea and vomiting, and one whose age was four months had had 
symptoms of invagination, when ten weeks old, which soon passed off. It 
is seen that the pre-existing affections were ordinarily such as would be 
likely to accelerate the movements of the intestines and at the same time 
render them irregular. 

Causes. — The above statistics, therefore, show that in a pretty large 
proportion of cases of intussusception, there is previous disease of the in- 
testine or derangement of its function. The two opposite conditions, 
namely, constipation and the diarrhceal maladies, so often precede the dis- 
placement that they must be regarded as common causes. Another prob- 
able cause is intestinal worms, which, by their mechanical action stimulate 
the intestines. They were present in three of the fifty-two patients, though 
two of the three seemed perfectly well till the occurrence of the intussus- 
ception. The other patient, immediately prior to it, complained of soreness 
around the anus, and ascarides were found on examination. 

The use of irritating and indigestible food is an occasional cause. Thus, 
some who have had intussusception have been in the habit of taking fruits, 
candies, and pastries freely. Such ingesta may be an immediate cause by 
their irritating eftect, or a remote cause giving rise to diarrhoea, which, in 
turn, produces intussusception. 

Rilliet and Barthez consider the sex a predisposing cause. There are 
more male than female children affected with intussusception. Of the 
twenty-five cases collated by them, all but three w^ere boys. In our own 
collection, the sex of thirty-four of the patients was recorded, and of these 
twenty-three were boys. 

In rare cases external violence is the apparent exciting cause. One 
patient received a severe contusion of the abdomen two years before death, 
and from this time continued to complain at intervals of pain in the 
bowels. One writer also mentions the case of a child nine years old who re- 



3 wore 


8 


m 


ontli; 


12 " 


4 






3 " 


5 






5 " 


6 






1 was 


7 






1 •' 


8 






3 were 


9 







6Q4: INTUSSUSCEPTION. 

ceived a blow from a comrade at school, and from this time had alternately 
diarrhoea and constij^ation till the invagination commenced. Rilliet and 
Barthez also relate the case of two children who were taken suddenly with 
invagination when their parents were tossing them in their arms. 

Age. — Of the fifty-two cases embraced in our statistics, the ages were 
as follows : 

1 was 10 months old. 
1 " 11 " " 

1 " 12 

2 were from 1 to 2 years old. 
8 " " 2 " 5" " " 
8 " "5 " 12 " " 

3 not given. 

There were, therefore, no cases- under the age of three months, 23 cases 
between the ages of three and six months, or nearly one-half of the entire 
number, 8 from the age of six months to one year, and only 18 between 
the ages of one year and twelve. These statistics correspond, in the main, 
with those of Rilliet and Barthez, in whose collection of 25 cases there 
was no one under the age of four months. 

The great liability to intussusception in infancy is due partly to the 
anatomical character of the intestine in this period of life, and partly, 
doubtless, to the fact that there are more frequent irregularities in the 
intestinal movements than in older children. In the infant the walls of 
the intestines are thin, the mucous and muscular coats and the connective 
tissue being much less developed than in those that are older; the mesen- 
tery and meso-colon have also greater depth as compared with the same 
in other periods of life, except the meso-colon at the points where it passes 
over the kidneys, in which places it is very short, or even in some cases 
nearly absent. Moreover, the space occupied by the large intestine, in 
which part of the digestive tube intussusception commonly occurs, is much 
shorter relatively to the length of the intestine than in those that are 
older. In about thirty measurements, which I have made of the length 
of the large intestine and the space occupied by it, the latter was found, 
in the average, about one-third that of the former, which, of course, neces- 
sitates doubling of the intestine on itself These peculiarities of structure 
in the iufant obviously favor the occurrence of intussusception. 

Seat and Pathological Anatomy. — While the simple or reducible 
variety of intussusception is usually multiple, the irreducible form is ordi- 
narily single. Tsvo exceptional cases will be presently related. In one 
recorded case there was a reducible in addition to an irreducible invagi- 
nation. 

"While the simple variety is seated in the small intestine, the seat of the 
irreducible form is, with occasional exceptions, the colon. The colon con- 
stitutes the entire invaginated mass, or else, and more frequently, it forms 



INTUSSUSCEPTION IN THE SMALL INTESTINES. 665 

the exterior, while the incarcerated portion consists wholly or in part of 
the ileum. 

Intussusception in the Small Intestines. 

Bouchut says: "M. Rilliet states, in a recent treatise, that in infancy 
the intestinal invagination is always accomplished at the expense of the 
large intestine, and that there is never invagination of the small intestine. 
This is incorrect. I have observed the small intestine invaginated in the 
adjacent inferior part. Taylor has reported a case of this kind in a child 
twenty months old, w4io died after an attack of acute peritonitis. M. 
Marage has seen another case in a child thirteen months old, who recov- 
ered after having voided the invaginated portion furnished with two of 
those diverticula so frequent in the small intestine of the foetus." 

But, from all that appears, the case reported by M. Marage may have 
been, and probably was, an example of the common form of intussuscep- 
tion, namely, of the ileum into the colon. In Mr. Taylor's case the in- 
vagination was really of the ileum into the colon, although a small portion 
of the ileum next to the valve had not been inverted, so that it constituted 
a little of the exterior of the mass. 

Nevertheless, Bouchut is correct in stating that irreducible and fatal 
intussusception may occur in the small intestines. Probably the displace- 
ment is at first of the simple variety, but, continuing and increasing in 
extent, its return becomes impossible. The positive statement of so great 
an authority as M. Rilliet, that intussusception with symptoms does not 
occur in the small intestines, justifies the publication of the following 
cases, which establish the fact that there are instances, though not fre- 
quent, in which the displacement does have this location : 

Case 1. — Male. This patient's health had been uniformly good, and 
nothing unusual was observed in his condition till the age of four and a 
half months, when he became restless as if in almost constant pain, with 
occasional exacerbations. Castor oil was prescribed, which operated freely, 
and then the following mixture: 

■ R. Magnes. calcinat., ^j. 

Tinct. opii camptioral., gij. 
Tinct. asafoet., ^ss. 
Aq. anisi, gj. Misce. 
Dose, ten to twenty drops, repeated according to the pain. 

These remedies failed to give relief, as did also chloroform given in doses 
of two drops. After two or three days, another set of symptoms arose, 
those characteristic of pneumonitis, namely, hurried respiration, accel- 
erated pulse, short, suppressed cough, and expiratory moan. He Ayas 
treated with the oiled-silk jacket, and mild counter-irritation, and took an 
expectorant mixture containing carbonate of ammonia. In a few days the 
pulmonary disease was evidently subsiding, but the pain in the abdomen, 
with occasional exacerbations, continued. His countenance was ])allid, 
and bore an expression of suffering. There was no distension or tender- 



66(j INTUSSUSCEPTION. 

ness of abdomen, and no abdominal tumor. He took little nutriment, and 
seldom vomited. In the last part of his sickness the dejections were scanty, 
and the last three days his stools consisted mainly of mucus and a little 
blood. The ])ain seemed to be growing less, when he was seized with con- 
vulsions, and died the same day, precisely two weeks from the commence- 
ment of his sickness. 

Sectio Cadaver. — Head not examined ; body slightly emaciated ; mucous 
membrane of trachea and bronchial tubes vascular ; posterior portion of 
the lower lobe of each lung solid, of a greater specific gravity than water, 
and allowing only partial inflation ; it was in the second stage of pneu- 
monitis. Stomach, duodenum, jejunum, healthy. In the upper part of 
the ileum was an intussusception two-thirds of an inch long, presenting no 
trace of inflammation, either within or^around it, and its vascularity, when 
it was examined externally, did not seem notably increased. Above the 
intussusception the intestine was empty ; below it, and chiefly in the small 
intestine, was a dark-colored substance evidently blood, and giving in a 
few hours the offensive odor of decaying animal matter. There was a pas- 
sage through the intussusception, at least two or three lines in diameter, 
as shown by a probe. The intussusception sustained the weight of sixteen 
inches of the intestine, and it would apparently have sustained consider- 
ably more. The remaining organs were healthy. 

Case II. — F. S., a female infant, four mouths old, was treated at the 
New York Infant Asylum in June and July, 1865, for entero-colitis, the 
usual epidemic of the summer season. The following records show the 
state of the bowels immediately before her death : 

June 29th. Has five or six stools daily. oOth. Two stools in twenty- 
four hours. July 1st. Had two stools since the last record ; no vomiting. 
3d. Four stools in last twenty-four hours. 4th. The diarrhcea continues 
as before ; stools about four daily. On the 6th of July she died. 



11//./// 



/ 



Her pulse during the time in which these records were taken generally 
numbered about 128 per minute. She was much emaciated, and the day 



INTUSSUSCEPTION IN THE SMALL INTESTINES. 667 

before death she frequently struck her head with the hand. The medi- 
cines employed were mainly alkalies and astringents. 

Sedio Cadaver. — Parietal bones united ; serous effusion lying over the 
convolutions of the brain, under the arachnoid ; occipital bone depressed; 
commencing at a point about two feet below the stomach were four intus- 
susceptions two or three inches from each other. The iuvaginated masses 
were from one to one and a half inch in length, and three of them were 
found to be very vascular in their interior. Above, between, and imme- 
diately below the intussusceptions the intestine was healthy. One of the 
invaginations was tested by weight, and was found to sustain one and a 
half foot of intestine, and would have sustained more. Water poured 
above these intussusceptions escaped through them very slowly; no fibrin- 
ous exudation ; descending colon vascular and thickened, and solitary 
glands enlarged. 

The irreducible character of the intussusceptions in the above cases was 
shown by the fact that they sustained weights which doubtless produced 
greater traction than that exerted by the intestine in its normal action. 
That the displacement existed prior to the moment of death was shown by 
the symptoms in one of the cases and by the anatomical changes in both. 
In one the capillaries of the incarcerated mass were ruptured during the 
last days of life, so as to produce sanguineous stools ; while in the other 
there was intense congestion of the invaginated mucous membrane, while 
that portion of this membrane which was adjacent but not engaged was 
healthy. 

In both patients the symptoms were less severe than in ordinary cases, 
and they came on more gradually, for the invaginated intestine was not 
completely closed, so that it allowed the passage of fsecal matter in one till 
the close of life, and in the other till near its close. At both of the au- 
topsies water poured into the intestines above the invaginations passed 
slowly through them. 

Intussusception in the small intestines in the infant, commencing as the 
simple form, may become irreducible, and yet remaining pervious may 
continue for weeks without giving rise to severe or dangerous symptoms. 
The following case was an example of this : 

Case. — IVIale child, died at the age of nineteen months, the last eleven 
of which he was under observation. The mother states that he had never 
been well since the age of one month, and that there had been little varia- 
tion in the symptoms of his disease. During the period in which he was 
under observation, he was ordinarily fretful, and frequently seemed to be 
in considerable pain. His stomach through this whole time was so irritable, 
that he rarely took more than three or four spoonfuls of nutriment without 
vomiting. There was usually more or less diarrhoea, but no tenderness or 
distension of abdomen. He became slowly but gradually more emaciated, 
and finally died in a state of extreme emaciation and exhaustion. He 
had no convulsions, and was conscious to the last. 

Sectio Cadaver. — Brain not examined ; lungs healthy, except a circum- 
scribed portion, which was inflamed, at the summit of the right lung ; liver 



6G8 IXTUSSUSCEPTION. 

small and almost destitute of oily matter, as shown by the microscope. 
In the jejunum, about two feet below the stomach, was an intussuscep- 
tion two inches lona:, the intestine forming which seemed to have under- 
gone no structural change. Above the intussusception the intestine was 
of small calibre, and entirely empty and pale; below the intussusception 
the intestine was somewhat larger than above, but it seemed quite healthy. 
The invagination was sufficiently pervious to allow water to pass through 
it, and it readily sustained the weight of two feet of intestine. From 
eight to ton inches below this intussusception there was another, which 
was immediately drawn out the moment the intestine was disturbed. The 
other abdominal viscera w^ere healthy. 

There is uncertainty as to the duration of intussusception in the above 
case, but the symptoms indicated that it existed a considerable time prior 
to death. There was no strangulation, nor indeed any appreciable ana- 
tomical alteration in the coats of the intestine, but the fact that the in- 
vagiuated mass sustained two feet of intestine, and required considerable 
traction for its reduction, shows that it was not a case of simple displace- 
ment occurring at the moment of death and without symptoms, but was 
an example of the irreducible variety. 



Intussusception in Large Intestines. 

In most cases of intussusception occurring in infancy and childhood, 
the ileum is invagiuated in the colon, or the first part of the colon is in- 
vaginated in the part succeeding it. Intussusception not unfrequently 
begins in the prolapse of the ileum through the ileo-coecal valve, in the 
same way that prolapse of the rectum occurs thi'ough the sphincter ani. 
If death take place early, only a small portion of the ileum may have 
passed the valve. If the case is protracted, the tenesmus brings down 
more and more of the ileum, with its accompanying mesentery. The con- 
striction of the valve, which acts as a ligature, soon prevents the further 
descent of the ileum ; and, the tenesmus continuing, the next step in the 
displacement is the inversion of the caput coli, which is drawn into the 
colon by the descending mass, and, unless the case terminate by sloughing 
or death, the ascending and transverse portions of the colon are succes- 
sively invaginated. The records show that intussusception occurs as above 
stated in a large proportion of cases. In one case, among those which I 
have collated the intussusception began a few inches above the valve, so 
that the ileum constituted a small portion of the exterior of the mass. 
Occasionally the coscum is the part primarily inverted and invaginated, 
and, descending along the colon, it draws after it the ileum, which sustains 
its natural relation to the ileo-coecal valve. AVhen this occurs the coecum 
is found at the lower end of the mass, and two orifices are observed, one 
leading through the valve, and the other into the appendix vermiformis. 
These two forms of invagination — that in which the ileum, passing through 



INTUSSUSCEPTION IN LAEGE INTESTINES. 669 

the ileo-coecal valve, successively inverts and draws after it the caput coli 
and the divisions of the colon ; and that in which the caput coli is primarily 
invagiuated, and descending along the large intestines, inverts the latter, 
and draws after it the ileum — constitute the vast majority of cases of this 
disease in the first years of life. 

I have notes of 45 fatal cases occurring under the age of twelve years, 
in which the portion of intestine first displaced is recorded. In four of 
these the displacement was entirely in the small intestine, involving in no 
way the colon ; in 38 cases it commenced either by prolapse of the ileum 
through the ileo-coecal valve, or by inversion of the coecum into the ascend- 
ing colon, there being perhaps not much diflference in the relative frequency 
of these two modes ; in one case the invagination was confined to a seg- 
ment of the transverse colon, in another to a segment of the descending 
colon, and in the remaining case to the lower part of the descending colon 
and the upper part of the rectum. In three instances the invaginated mass 
itself became invaginated, producing an intussusception of great thickness 
and necessarily fatal. 

As we have seen in regard to intussusception in the small intestines, so 
that occurring in the large intestine may be attended by so little constric- 
tion of the incarcerated portion that it remains pervious, though with 
diminished calibre. In such a case life may be protracted for weeks or 
even months, without reduction of the displacement or any material 
change in it, the passage of faecal matter being sufficiently free for the 
maintenance of life. Death finally occurs in a state of exhaustion. Thus in 
one instance a child, four months old, lived six weeks after the symptoms of 
invagination commenced, and seventeen days "with a portion of the bowel 
protruding from the anus." It was found at the post-mortem examination 
that part of the ileum had descended through the entire colon, and had 
remained pervious. In a case related by Dr. Worthington in the Amer. 
Jour, of Med. ScL, for January, 1849, there were symptoms of intussuscep- 
tion for seven months before death, and during the last six weeks of life, 
the invaginated intestine protruded frequently from the anus, and was 
replaced by the mothei\ In this case " the coecum was inverted, and de- 
scended through the colon to the lower portion of the rectum, carrying 
with it the ileum and the entire colon, except the last ten or twelve 
inches." In another case the symptoms indicated a continuance of the 
disease for three, if not eight, months. But such cases are exceptional. 
Ordinarily as the intestine becomes invaginated, its mesentery or meso- 
colon is also invagiuated, and its veins compressed. The pathological 
state of the incarcerated mass soon becomes that of intense congestion. 
In infants, usually in a few hours, so great is the distension of the capil- 
laries that they give way, blood escapes into the intestine, and passes from 
the bowels in scanty motions. On examining the invaginated intestine 
after death, if gangrene has not occurred, it is found of a uniform intense 



670 INTUSSUSCEPTIOX. 

red color, sometimes resembling to the uaked eye a long and firm clot of 
blood. In those who die early there are no traces of inflammation, but in 
more protracted cases the attrition between the serous surfiices excites local 
peritonitis. But in none of the fifty-two cases which I have collated in 
which post-mortem examinations were made, did the inflammation extend 
more than a few lines beyond the invagination. Usually the intestine 
forming the exterior of the invaginated mass is much drawn together or 
puckered. In one case treated by myself, the entire large intestine which 
formed the exterior of the mass was compressed within a space of six inches 
or less, since about twelve inches of the ileum, doubled on itself, lay witMn 
the entire colon and protruded from the anus, the only part of the large 
intestine which was inverted being the caput coli. In one case six or seven 
inches of the ileum, which formed a portion of the exterior of the mass, 
were compi-essed within the space of one inch. 

The abdomen, at first of natural fulness and soft, usually becomes more 
and more distended till the close of life ; but in cases of much vomiting 
the distension is moderate. This fulness is due to gas and faecal accumu- 
lation above the invagination. The portion of intestine below the displace- 
ment is ordinarily empty, except that in the infant it ordinarily contains 
mucus, mixed with more or less blood, which has escaped from the capil- 
laries of the strangulated mass. 

There are few anatomical changes in this disease, which do not arise 
directly from the intussuscepticm, and are, therefore, located either w'ithin 
the mass or in its immediate vicinity. In those who recover by the pro- 
cess of sloughing, the cicatricial contraction may give rise to symptoms 
and lesions of greater or less gravity. Thus the late Sir James Y. Simpson 
examined a child aged 9 years, who recovered with loss of ten inches of 
intestine, and at the meeting of the Medical Society, before which the speci- 
men was presented, remarked that there was unusual distension of the cu- 
taneous veins of the patient, due probably to such compression of the ascend- 
ing vena cava by the cicatrix, that the venous circulation was obstructed. 
(Trans. Medico- Chir. Soc, 'Ed'm.) In the London Lancet, for 1854, Mr. 
Charles King relates the case of a child aged 6 years, who, on the eleventh 
day of the disease, voided the coecum and a part of the colon. Two days 
subsequently pulsation ceased in the left leg, and all that part below the 
patella became grangrenous. The patient gradually recovered with loss 
of the leg. The cause of this unfortunate sequela was doubtless compres- 
sion from the cicatricial contraction of the artery which supplied the leg, 
and probably the formation of a thrombus. In the Lond. Med. and Phys. 
Jour., for December, 18th, 1823, Dr. F. Bush relates a case in which he 
was enabled to observe the extent and appearance of the cicatrix. The 
patient, aged 12 years, discharged from the bowels fifteen to eighteen inches 
of the ileum on the eighth day of the intussusception, after which convales- 
cence was rapid. Fourteen weeks later the child died from typhus fever, and 



SYMPTOMS. 671 

at the autopsy " traces of the diseased bowels were visible by a contrac- 
tion and puckering where the slough had taken place, and the parts united." 
But fortunately in most instances when the intestine sloughs and the child 
survives, no serious or permanent injury results from the cicatrization. The 
cicatrix stretches little by little, and accommodates itself to the surround- 
ing parts. 

Symptoms. — The symptoms vary according to the age of the patient and 
the degree of strangulation. Pain in the abdomen, usually paroxysmal, 
is among the first, and is one of the most conspicuous symptoms. It is 
often severe, resembling the pain of hernia, and abating only with the 
failing strength of the child. After the first few days, if inflammation 
arises, the pain is continuous, though more severe in paroxysms. At first 
pressure upon the abdomen is tolerated, but afterwards there is tenderness. 
This is due to the inflammation, which occurs in and around the invagi- 
nated mass, and it is, therefore, confined to the part of the abdomen in which 
the tumor lies. At this point also the abdomen is more full than else- 
where, and not unfrequently the physician can feel the invaginated mass 
and detect its exact location, and approximately its extent. Sometimes, at 
an early period as well as late, cerebral symptoms occur, as in a case re- 
lated by Dr. Coggswell in the London Lancet, for July, 1853, which termi- 
nated in convulsions and death on the second day. Convulsions ai'e, 
however, comparatively rare, and the mind is generally clear till the last 
moment. In infants the countenance, in the intervals of pain, in the first 
stages of the complaint, is often placid and not indicative of any serious 
disease, but in older patients constant and severe local symptoms, referable 
to the intussusception, commence early. At an advanced period, whatever 
the age, the countenance becomes anxious and haggard, the eyes hollow or 
sunken, the body loses its plumpness, and, if the case is protracted, becomes 
emaciated. 

Vomiting is rarely absent ; in thirty-nine out of forty-seven cases it is 
stated to have been present ; in seven cases there is no record of this symp- 
tom, while it is recorded absent in only one case ; but in this case, the 
records of which are very meagre, death occurred on the second day. 
The vomiting becomes stercoraceous in a few days, and it ordinarily con- 
tinues with greater or less frequency till the period of collapse. It relieves 
partially the distension. 

The appetite is impaired and often entirely lost. Infants at the breast 
commonly nurse, however, for several days, probably from thirst rather 
than hunger. 

There is commonly one natural evacuation from the bowels after the 
intussusception commences, and then obstinate constipation succeeds. This 
evacuation consists of the excrementitious matter below the invagination. 
In children under the age of one year, scanty motions of blood mixed 
with mucus begin to occur in a few hours. In twenty-seven children 



672 INTUSSUSCEPTION. 

under this age I find that twenty-four had such evataiatious, occurring in 
most of them several times in the course of the day ; in two of the twenty- 
seven there is no record of this symptom, but in the remaining case it is 
stated to have been absent. Scanty evacuations of blood unmixed with 
fsecal matter have been considered pathognomonic of intussusception in 
the infant, and we see the ground for such belief; bnt in exceptional in- 
stances the invagiuated mass is partly pervious, and although the dejec- 
tions may contain blood they are also excrementitious. In our collection 
of cases are three examples of this in infants under the age of one year. 
One has already been referred to. In this case there was the rare anomaly 
of so large an opening through the ileo-cojcal valve, as to allow not only 
prolapse and descent of the ileum through the entire colon, so as to pro- 
trude six inches from the anus, but also fsecal passages through it daily. 

In children above the age of one year, the capillaries of the invaginated 
intestine are not so frequently ruptured as under this age, and sanguineous 
evacuations are therefore less common. I have records of nineteen cases 
between the ages of one year and twelve, in only six of which is it stated 
that there were bloody motions, and in these the blood was not passed fre- 
quently, nor even in some cases daily, as in infants, nor in so pure a state, 
unless in two cases, the records of which are not explicit on this point. 
Two of these six patients passed moderate bloody evacuations after pro- 
tracted periods of constipation, one had fiecal discharges with the blood 
through the entire sickness, and in one blood was passed at first, but finally 
the stools were entirely fsecal. 

In those above the age of one year, there was for the most part obstinate 
constipation, no dejections, whether bloody or ftecal, occurring for several 
days, but there were a few exceptions. In three cases the bowels were 
relaxed. The ileum, in these three, had descended through the entire 
colon, or the larger part of the colon, and being pervious, the fa3ces escaped 
from the anus without detention in the large intestine, or with detention 
only in its lower portions, and w^ere therefore liquid. 

Tenesmus is another symptom. It is not always present, but in a large 
proportion of cases, even when the invagination is in the upper part of 
the large intestine, it is a frequent and distressing symptom. It often does 
not commence till there is a considerable amount of displacement, and it 
ceases when the strength is much reduced. 

The temperature of the surface is normal in the commencement of 
intussusception ; but finally, as febrile reaction comes on symptomatic of 
the inflammation, it rises and continues above the healthy standard till 
the intestine sloughs, or till the stage of collapse occurs which ushers in 
death. The pulse, especially in the infant, is tranquil at first, but, what- 
ever the age, it soon becomes accelerated from the paroxysms of pain, and 
subsequently from the inflammation which occurs in the invaginated mass. 
There is no disturbance of respiration, except that it is somewhat hurried 



DIAGNOSIS — DURATION. 673 

from the fever, and from the paiu felt in advanced cases on full inspira- 
tion. 

It will be seen that the symptoms vary in certain particulars, under the 
age of one year, from those occurring over that age, but differences in the 
symptoms depend more on the degree of invagination and constriction, 
than on the age and exact location of the disease. 

Diagnosis. — The diagnosis of intussusception is not, in general, diffi- 
cult, except at its commencement. When the inversion has reached that 
degree at which obstruction occurs, the symptoms are, in most cases, such 
that the disease can be readily diagnosticated. In the cases whose records 
I have collated a correct diagnosis was, with few exceptions, made, and at 
an early period. In the infant, the disease for which intussusception is 
most frequently mistaken is dysentery, on account of the tenesmus and the 
muco-sanguineous stools. In certain of the reported cases this mistake 
was not rectified until it was ascertained that purgatives produced no fsecal 
evacuations. 

The symptoms which are commonly present, and which indicate the na- 
ture of the disease, are obstinate constipation, vomiting, paroxysmal paiu 
referred to the seat of the disease, and tenesmus. In the infant, also, scanty 
evacuations from the bowels of mucus and blood, or of pure blood, is, as we 
have seen, an important diagnostic sign. It should be borne in mind, 
however, that in exceptional cases the displaced bowel may remain per- 
vious, and the usual symptoms which possess diagnostic value therefore 
be absent. There may be no vomiting or tenesmus, and there may even 
be diarrhoea in place of constipation, as in the cases related above. As an 
aid to diagnosis, it should be stated that whatever the age of the child af- 
fected with intussusception, clysters are often administered with difficulty, 
and are quickly and forcibly returned, on account of the resistance op- 
posed by the invaginated mass. We have stated above that the seat and 
even extent of displacement can be ascertained in a large proportion of 
cases by digital examination of the abdominal walls. The tumor can be 
felt hard, elongated, and tender on pressure, so that the diagnosis is clear. 
If the invagination be in the lower part of the large intestine, it can some- 
times be discovered by an examination per rectum. 

Duration. — In the following table, the duration of the intussusception 
in forty-nine cases is given, as nearly as it can be ascertained from the 
records : 

1 died tlio 8th day. 

1 " " 10th " 

1 " " 14th " 

1 lived nearly a week. 

1 " 6 weeks. 

3, time of death not given. 

7 recovered. 



2 died th( 


3 1st day. 


6 " " 


2d " 


14 " " 


3d " 


2 " " 


4lh " 


5 " " 


r.tli " 


2 " " 


fith " 


2 " " 


7th " 


1 lived over a week, 



674 INTUSSUSCEPTION. 

lu two of the three cases iu which the duration is not stated, the patients 
lived much longer than the usual period. One of these two, a girl of six 
years, having eaten raw carrots, was seized with pain in the abdomen, which 
lasted eight months, when she died. During the last three months she 
passed mucus and blood. In this case the coecuni had descended to the 
anus, drawing with it the ileum, which remained pervious. The symptoms 
indicated the continuanceof the invagination for three months if not eight. 
The other patient was a boy, aged 3 years, 4 months, who complained of 
pain in the abdomen for many months, and occasionally vomited. During 
the last six weeks of his life, all the phenomena of invagination were present. 
In this case also, the inverted caput coli had descended along the entire 
length of the colon, and it lay at the autopsy in the rectum. 

In AVest's Treatise on Diseases of Children (fifth edition, 1866, page 504), 
it is stated that death iu this complaint always occurs within a week. The 
above statistics, however, show that there are exceptions to this statement, 
although a large majority do die within the first seven days. In thirty- 
three of the cases embraced in my statistics death occurred within the first 
week, and in no fatal case in which strangulation was complete was life 
prolonged beyond the eighth day. In these cases of complete strangula- 
tion the average duration was 3.7 days, and the largest number of deaths 
occurred on the third day. Death on the first day is rare, but it occurred 
in two instances. When so early it is often, if not generally, in convul- 
sions and coma. 

Prognosis. — Intussusception is in its nature so grave an accident that 
the physician called to a case should always expect and predict a fatal re- 
sult. A favorable issue is only through an unusual combination of circum- 
stances. But, while death is the common result, there are three different 
modes of termination in which life is preserved. First, the reduction of 
the incarcerated intestine, with immediate relief. There can be no doubt 
that it is possible for intussusception, when recent, to be reduced by the 
unaided action of the bowels, in the same way as the common, simple in- 
tussusception iu the jejunum and ileum, or as hernia is reduced, through 
the vermicular action of the intestines. For sometimes, as in Dr. Coggs- 
well's case (Loud. Lancet, July, 1853), the patients "at some previous time 
have experienced the same symptoms as those which accompanied the at- 
tack, and which subsiding, they remained for a time in perfect health. This 
termination is probably rare, if the symptoms are sufficiently marked to 
necessitate treatment. Again, the intussusception may be cured by early 
and well-applied treatment. The physician may succeed in reducing the 
displaced intestine, even if the intussusception is in the upper part of the 
colon. 

A second mode of favorable termination is alluded to by certain foreign 
writers. The intussusception continues for a considerable period with the 
characteristic symptoms, and then, as Bouchut expresses it, " the vomit- 



PROGNOSIS. 675 

ings gradually cease, the intestinal hsemorrliage disappears, the strength 
returns, and the health becomes restored without the expulsion of frag- 
ments of the intestine." What changes the displaced intestine undergoes 
in these protracted cases, which gradually recover without sloughing, have 
not been clearly ascertained, although they have been the subject of con- 
jecture. According to Rilliet, a large proportion of favorable cases ter- 
minate in this manner. It does not appear, however, from the statistics 
which I have collected, that this is a common mode of recovery. The 
clinical history of intussusception establishes the fact that in a large ma- 
jority of protracted cases there is either death or the third mode of favor- 
able termination, namely, by sloughing. 

Infants with intussusception other than the simple form, which was 
described at the beginning of this paper, commonly die. The reason of 
this is obvious when we consider that, in a few hours after the invagina- 
tion begins, the imprisoned mass, with now and then an exception, becomes 
so congested that its capillaries give way, and its reduction is impossible 
by any appliance of medical art. We cannot reasonably expect recovery 
except through sloughing and the expulsion of the intestine ; and few 
infants have tlie requisite strength for so tedious and exhaustive a process. 
The youngest child that recovered in this way, so far as I have been able 
to ascertain, was an infant thirteen months old, whose case was reported 
by M. Marage. With the exception of this case, the youngest was a boy, 
aged five years. The older the child, the greater, of course, the power of 
endurance, and the better the prospect of recovery. Of the fifty-two cases 
whose records I have collated, seven recovered by the sloughing and ex- 
pulsion of the mass. These children were of the ages of five, six, six, 
nine, eleven, twelve, and twelve years. The separation of the invaginated 
mass occuiTcd in six of these between the sixth and twelfth days, with an 
average of nine and a half days, the time not being given in one case. 
If, then, the patient can be carried through the first week without too 
much exhaustion, we may each day look for the discharge of the slough, 
the reopening of the bowels, and ultimate recovery. 

In those cases in which the intussusception remains open, so as to allow 
the passage of fsecal matter, recovery is improbable unless the displace- 
ment is diagnosticated early and properly treated. If the intussusception 
continues, it becomes greater and greater from the absence of strangula- 
tion. Without inflammation and with little or no congestion of the dis- 
placed portion, and without the severe symptoms which occur in ordinary 
cases, the patient wastes away, having irregular evacuations and more or 
less abdominal pain, and finally dies in a state of emaciation and weak- 
ness. In the early stage of this form of displacement it is not improbable 
that injections or inflation, employed with suflScient force, will give relief, 
but, if the early period passes without such treatment, cure is impossible 
by the ordinary methods. It is in such instances, to wit, those in which 



676 INTUSSUSCEPTION. 

the displacement occurs without strangulation or inflammation, and in 
which fecal matter passes through the displaced mass more or less freely, 
that lapai'otomy is justifiable, and is likely to give relief, when injections 
and inflation have been employed in vain. Jonathan Hutchinson's suc- 
cessful performance of this operation in a child of two years, who had 
this kind of displacement, is known to most readere. (See London Lancet, 
November 22d, 1873.) 

The prognosis is most favorable when the displacement occurs in the 
lower part of the large intestine, for its reduction is then comparatively 
easy. An interesting case of this kind was observed and treated by Drs. 
O'Dwyer, Reid, and myself, in the Catholic Foundling Asylum, in 1875. 
The child was a female, aged two years, and had had previous good health. 
The invaginated mass protruded like a prolapse, about four inches outside 
of the anus. It was cold, considerable haemorrhage had occurred from it, 
and the infant seemed in collapse. When the mass was returned so far 
as it could be carried within the pelvis, by the index finger, the lower end 
of it could still be felt like an os uteri. It protruded four or five times 
within twenty-four hours, but, by replacement so far as possible with the 
fingers, and the use of simple water injections, it was finally permanently 
reduced, and, with the use of stimulants, she soon fully recovered. 

Modes of Death. — This is different in different cases. It sometimes 
occure from collapse. At a meeting of the New York Pathological So- 
ciety, held December 10th, 1873, I presented a specimen, showing intus- 
susception occurring about one foot above the ileo-coecal valve, in an 
infant aged thirteen months. On the day before its death, its previous 
health having been good, it seemed ill, and vomited once or twice, but did 
not appear to be in pain. It had two evacuations from the bowels, of the 
usual appearance, in the latter part of the day. On the following morn- 
ing it was unexpectedly in collapse, and died within about twenty-four 
hours from the commencement of the sickness. At the post-mortem ex- 
amination the head was not opened, and all the organs of the trunk were 
found normal except the intussusception. The mass involved in the dis- 
placement m^easured two and a half inches in length, and was slightly 
crescentic. The mucous membrane above and below it had the normal 
appearance, as did that of the external or incarcerating portion of the 
mass, while that of the incarcerated part was deeply injected. Water 
poured into the intestine above the invagination was wholly arrested by 
it. (-ZV. Y. Med. Rec, April 1st, 1874.) But in the majority of instances 
death occurs from asthenia, which comes on gradually, but increases rap- 
idly in consequence of the pain, vomiting, and imperfect nutrition. Chil- 
dren dying in this way may have convulsive movements more or less 
marked, but the prevailing characteristic as death approaches is extreme 
exhaustion. In exceptional instances the life of the sufferer is cut short 
by convulsions before the stage of exhaustion is reached. Thus a child, 



TREATMENT. 677 

aged three years, whose case was reported by Dr. Isaac Thomas, in the 
Amer. Med. Recorder, in 1823, and another, aged two years, whose case 
was reported by Dr. Coggswell, in the London Lancet, July, 1853, died in 
convulsions on the second day. 

Treatment. — It is unfortunate, in cases of intussusception, that the 
time in which treatment can be of most service is apt to pass by before 
the true condition of the intestine is detected. Invagination being com- 
paratively rare, the patient is generally on the first day treated for colic 
or dysentery or some other common affection of the bowels ; and it is often 
not till the second day, when the intestine has become incarcerated, that 
the physician accurately diagnosticates the disease. The purgative medi- 
cines usually given in the commencement injure the patient. In fact, 
both reason and experience teach us the impropriety of such treatment in 
this complaint. Cathartic remedies act as a vis a tergo, and may cause a 
still further descent of the inverted intestine. Yet such powerful agents 
of this class as quicksilver have been employed. It was administered in 
two doses of one ounce each in one of the cases embraced in my statistics, 
but none of the mineral passed the bowels. At the post-mortem examin- 
ation a considerable part of it was found in small globules, coated with a 
black layer consisting of the sulphuret or black oxide of mercury, in the 
intestine above the intussusception. It need not be added that the case 
Avas speedily fatal. 

The proper treatment of intussusception consists in attempts to reduce 
the displacement by pressure from below. This pressure may be applied 
either by liquid injections into the rectum, or by inflation of the lower 
intestine by air or gas. 

Injections should be made with lukewarm water for cold or hot water 
may cause contraction of the muscular fibres of the intestine, and increase 
the constriction. The child should be placed in bed, or in the nurse's lap, 
with the nates elevated 45°. With the common india-rubber, or better the 
fountain syi'inge, and the aid of an assistant, the liquid should be gently 
thrown into the rectum until the abdomen is somewhat distended. By 
carrying the fingers, firmly but gently applied upon the abdominal walls, 
along the direction of the colon, the liquid is made to press against the 
lower end of the intussusception. The same gentleness and perseverance 
is required in kneading and pressing the abdominal walls as in the treat- 
ment of hernia, by taxis. If the invagination is in the descending colon, 
probably only a small quantity of the liquid can be injected, and it may be 
forcibly returned, but by repenting the injections, a sufficient quantity can 
ordinarily be introduced to obtain the full eftect of this mode of treatment. 
There is also sometimes, an increased irritability of the rectum, even when 
the intussusception is at the other extremity of the large intestine, so that 
tenesmus and expulsive efforts follow the iiitroduction of the instrument. 



678 INTUSSUSCEPTION. 

The assistant can aid iu overcomiug tliis by pressing tlie soft parts of the 
nates around the instrument. 

If the injection fail to reduce the displacement, it may be repeated after 
allowing the patient to rest for awhile. In the Neiv York Medical Journal 
for May, 1875, is the history of an interesting case, which was treated by 
Drs. Church and Warren, of this city, and is reported by the latter. The 
infant was seven months old and had the usual symptoms, such as frequent 
paroxysmal pain iu abdomen, vomiting, tenesmus, scanty rauco-sanguineous 
stools. On the third day injections were twice employed without result, 
but on the fourth day an injection often or twelve ounces reduced the dis- 
placement, and the infant recovered. In a second case treated by Dr. 
Warren the age was nine months, and a tumor appeared a little above 
the umbilicus a few hours after the commencement of the symptoms. The 
following is Dr. Warren's account of this interesting case which will give 
a clear idea of the proper mode of treatment : 

" The patient was looking very pale and prostrated, the pulse was quick 
and feeble, and the skin cold. I at once determined to use fluid injections, 
and, with the little patient placed in a semi-prone position in his mother's 
lap, with an ordinary Davidson syringe I commenced injecting tepid soap 
and water, but after perhaps a gill had been thrown into the rectum it was 
almost immediately rejected, very highly colored with blood, and mixed 
with it a very small quantity of mucus and faecal matter ; the latter, by 
the way, not hardened, but of the consistency of soft putty. In a second 
attempt the fluid was retained longer, but was after a little while dis- 
charged, with more blood and mucus, but with much less tenesmus and 
pain. 

" When, soon after, I made my third attempt, the child's chest was rested 
upon the side of its mother's lap, with the lower extremities elevated by an 
assistant, so that the position was at an angle of about 45°, anus upward. 
This time I injected the fluid veiy slowly, in order to avoid, if possible, 
the irritation caused generally by the frequent emptying and refilling of 
the syringe (which, by the way, is a very serious hindrance to the success- 
ful use of this syringe, and which renders it much inferior to the fountain 
or hydrostatic). In thi-s manner I succeeded in injecting, as I estimated 
at the time, perhaps ten or twelve ounces, and during the operation the 
child gradually became more quiet, and had, when I ceased, fallen asleep. 
Then, with the direction that occasional doses of tinct. opii camph. should 
be administered during the night, to control, if possible, the peristaltic ac- 
tion of the intestines, I left him. 

" On the following morning, to my surprise, I found the child sleeping 
quietly and naturally, and I was informed that at about 5 A. M. (six hours 
after my visit) he had a movement of the bowels, which was saved for my 
inspection, and consisted simply of the enema, slightly colored with fsecal 
matter. From that time he seemed to be entirely free from pain, and six 



TREATMENT. 679 

or seven hours later had a natural passage, after which recovery progressed 
rapidly, and in a few days he was discharged well." 

Injections in order to be effectual, and give promise of success, must be 
aided by gravitation. Unless the nates are so elevated as to obtain the bene- 
fit of this hydraulic principle, I am convinced that inflation is more likely 
to reduce the displacement, and if after sufficient trial of injections, relief 
is not obtained inflation should be employed. Inflation, as compared with 
liquid injections, produces a more equable and effective distension of the 
external or incarcerating portion of intestine, and cases of cure by infla- 
tion have been reported after injections had failed. Treatment by infla- 
tion, which indeed ought to occur to any intelligent physician, appreciating 
the anatomical condition of the parts, as the correct mode, was prominently 
brought to the notice of the profession in modern times by Mr. Samuel 
Mitchell, in a communication to the London Lancet for March 17th, 1838. 

" I take the liberty," he writes, "of suggesting to the profession, through 
the medium of your valuable periodical, the trial of inflating the bowels 
by means of a glyster-pipe attached to a common pair of bellows ; it has 
fallen to my lot to witness several of these most distressing cases in 
children ; the nature of the obstruction was foretold during life, and un- 
fortunately verified by post-mortem examination. The last case of the 
kind which came under my care, about two years since, pi-esented all the 
usual symptoms : intolerable restlessness, the most obstinate sickness, the 
singularly distressed state of countenance, and shrunken features. The 
usual remedies were had recourse to, viz., warm baths, glysters, anodyne 
frictions over the abdomen, etc., but without avail. As a forlorn hope 
I made trial of inflation by the above means, with the most happy re- 
sult. The sickness immediately ceased ; the child within an hour passed 
a natural stool, and in the morning was almost without ailment." 

This mode of treatment is termed novel in the Lancet, but it is really as 
old as the time of Hippocrates, who speaks of throwing air into the bowels, 
by which flatulence is imitated (flatus immitatur). {Hippocrates' Works, 
translated from the Greek by Grimm, 4 bd., page 198.) Haller also rec- 
ommended the same treatment : " Flatus etiam immissus celerrime suscep- 
tionem dispellet." (Physiologia Corporis Humani, tom. vii, p. 95.) In the 
Edinburgh Medical Journal, October, 1864, Dr. David Greig relates five 
cases of successful ti'eatment of intussusception by inflation. The first, an 
infant six months old, previously in good health, suddenly became very 
fretful, apparently having severe paroxysmal pain in the abdomen. She 
had vomiting, and finally tenesmus, with bloody evacuations. Warm 
water enemata could not be employed on account, the writer thinks, of 
the spasmodic action of the intestines, and an abdominal tumor could 
be distinctly felt near the umbilicus. Castor oil and a purgative powder, 
and enemata of water having been employed in vain, and the case becom- 
ing really critical on the second day, inflation was resorted to. The writer 



680 INTUSSUSCEPTION. 

says: "The nozzle of a small pair of bellows was introduced into the anus, 
and air injected to a considerable extent. Contrary to our expectation, 
the air passed readily into the bowel, and seemed to give the child great 
relief. After the injection it lay very quiet, as if asleep, and evidently 
quite free from pain. In about twenty minutes from the time the air in- 
jection was administered a slight rumbling noise was heard in the child's 
abdomen, followed by a crack so loud and distinct as to alarm the at- 
tendants in the room, who thought something had burst in the child's 
bowels. The child, however, continued as if asleep and free from pain, 
and in about half an hour a large feculent stool, slightly mixed with blood 
and mucus, was parsed without pain. During the night the child rested 
pretty well, had no return of vomiting, took the breast as usual, and in 
two days was quite well." 

Another child, nine months old, treated by Dr. Greig, presenting nearly 
the same symptoms and the abdominal tumor, also obtained relief by in- 
flation, after castor oil and enemata had failed to produce any benefit. 

An apparatus for the production and injection of carbonic acid gas has 
been invented by Schultz and Warker, of this city, and is manufactured 
by them. It consists essentially of two glass chambers, one over the other. 
In the lower one a bicarbonate is placed, and in the upper an acid in a 
liquid state. By the gradual admixture of the two, carbonic acid is set free. 
An elastic tube conveys the gas from the lower chamber. This apparatus 
has been used by physicians of the city for the reduction of intussuscep- 
tion and other purposes, and is a useful invention. 

The same firm, and several others in this city, prepare for the shops 
quart bottles of highly charged carbonic acid water, from which when 
inverted a powerful current of carbonic acid gas can be obtained. Two 
or three of these bottles, with a portion of the tube from Davidson's 
syringe, which can be readily attached to the stem from which the gas 
escapes, constitute all that is required for an ordinary case. 

The following cases, which I treated with Dr. Biichler, of this city, in 
1871, show what may be achieved by inflation, and also the unfavorable 
result which must inevitably occur in certain cases. A German infant, 
five months old, nursing, began to be fretful, crying often on March 7th, 
and before night passed a scanty motion of blood. The symptoms con- 
tinuing, I was asked to examine the infant on the 10th, and learned the 
following facts : It had vomited daily, had had daily scanty but infrequent 
stools, consisting chiefly of blood, accompanied at first by tenesmus, but 
not within the last day ; it continued to nurse, but was becoming thinner 
and weaker, and was evidently in pain. The symptoms indicating the 
nature of the disease, the abdomen, which was not distended, was ex- 
amined for the tumor, which was found in the right side in the site of the 
ascending colon, apparently about one and a half to two inches in leiagth ; 
pulse 124 in sleep ; no cough. An ineffectual attempt was made to reduce 



TREATMENT. 681 

the iDtussusception by a very rude and imperfectly constructed apparatus 
(the bellows), Avhen from the lateness of the hour farther treatment was 
postponed till early the following morning. 11th. Tumor still detected 
in the right lumbar region ; pulse 120 asleep, 150 awake. By means of 
Schultz and Warker's apparatus, the intestines were inflated so as to pro- 
duce very decided prominence of the abdomen, and the abdomen gently 
kneaded. After some minutes the gas was allowed to escape, when the 
tumor had disappeared. In a few hours, a natural evacuation occurred 
from the bowels, and the infant has remained well since. 

The second case ended unfavorably, although the symptoms were appar- 
ently no more grave than in the case just related, and had continued a 
shorter time. This infant was also of German parentage. The tumor, 
firm and elongated, could be distinctly felt in the left lumbar region. In 
this case the inverted bottles of carbonic acid water were employed, and 
when, after considerable delay and kneading of the abdomen, the gas was 
allowed to escape from the intestine, the tumor had disappeai'ed. A few 
hours afterwards convulsions occurred, ending fatally. At the autopsy the 
invaginated mass, which was too firmly strangulated to admit of reduction 
by inflation, was found in the epigastric region, having been carried up 
from its former position by the inflation of the intestine below. It con- 
sisted of the terminal part of the ileum, which had passed through the 
ileo-ccecal orifice, and become incarcerated in the ascending colon, and, as 
is not unusual in these cases, the action of the intestines had changed the 
location of the tumor in the abdomen from the right to the left side. 

Whether air or carbonic acid is employed, it is necessary to produce 
distension of the intestine to its fullest extent below the seat of the com- 
plaint, without endangering rupture, and of course the sooner it is used 
the better the chance of success. In a few days the displaced intestine 
has, in a large proportion of cases, become so firmly incarcerated, and has 
descended so far, that attempts to replace it, either by injections or infla- 
tion, are unsuccessful ; still, even at a late period, a persevering attempt 
should be made if it has not previously been tried. If injections and in- 
flation fail to effect the desired result, the employment of quicksilver, by 
the rectum with the thighs elevated, has been suggested to me as worthy 
of trial by a physician of large practice in this city, who has had con- 
siderable experience with intussusceptions. This may be a useful sugges- 
tion, especially if the invagination has passed into the descending colon. 

If the modes of treatment which I have recommended above, fail to 
give relief when perseveringly and sufficiently employed, the patient's state 
is one of extreme peril, and the prognosis is unfavorable. Yet recovery 
is possible in one of two ways, namely, by incision through the abdominal 
walls (laparotomy), and reduction of the displacement by the fingers within 
the abdomen, and secondly, by sloughing of the invaginated mass, and 
union by adhesive inflammation of the ends of the intestine which have 



682 INTUSSUSCEPTION. 

preserved their vitality- Atrophy of the imprisoued part so seldom occurs 
in a case which has resisted injections and inflation, that it need not be 
considered in this connection, as a mode of recovery. 

Laparotomy has been successfully performed in a child aged two years, 
as I have stated above, by Dr. Jonathan Hutchinson, of London. The case 
was one of those exceptional ones in which great displacement had oc- 
curred without strangulation. It had continued as indicated by the symp- 
toms about one month, and a portion of the intestine terminating in the 
ileo-coecal valve had extended several inches from the anus. "The patient 
was anesthetized by chloroform, and the abdomen was opened in the mid- 
dle line below the umbilicus. The intussusception was then easily found, 
and as easily reduced. The after-treatment consisted only in the adminis- 
tration of a few mild opiates, and the child made a rapid recovery." (See 
London Lancet, November 22d, 1873.) In a case of this kind, there can 
be no doubt of the propriety and necessity of laparotomy as a last resort, 
for there being no strangulation, sloughing could not occur, and death 
sooner or later, from exhaustion, must be the inevitable result. Cases of 
this sort have usually been left to perish, after the ordinary modes of relief 
have failed. Thus as far back as 1784, M. Robin published in the Mem. 
de VAcad. de Chirurg., the case of a child aged 3i years, who died after 
the lapse of three months, with the coecum protruding from the anus. 
And in the Aner. Jour, of Med. ScL, for 1849, Dr. Worthington published 
a similar case, in which a child aged three years and four months, lived 
even a longer time. In these days of anaesthetics, and with the brilliant 
success of Hutchinson, a physician would in my opinion be reprehensible 
if he allowed a child aged two years or over, with this form of the dis- 
l^lacement, to perish without strongly advising laparotomy. 

But as we have seen in a majority of instances, invagination occurs under 
the age of one year, and if it is not reduced within a few days, it becomes 
strangulated, and inflammation occurs at the point of constriction. The 
conditions are obviously unfiavorable for abdominal section, but it has been 
performed at least five times in children having displacement of this sort 
with a uniformly fatal result. The reader will find the histories of four of 
these cases in an interesting paper on laparotomy, published in the Amer. 
Jour, of 3fed. ScL, for July, 1874. With such statistics, and knowing that 
recovery is possible by sloughing of the invaginated mass, the prudent 
physician will, in my opinion, be deterred from laparotomy if the symp- 
toms indicate strangulation and inflammation. He will prescribe emol- 
lient poultices over the bowels, with the internal use of opiates and sustain- 
ing measures, and await the result. 

The diet in intussusception should consist of beef juice or other concen- 
trated nutriment, which leaves little residuum. Vomiting, which is so 
common, is best controlled by bismuth and opiates. It serves to relieve 
the fsecal accumulation and distension. Convulsions require the bromide 
of potassium and a warm bath. 



SECTION lY. 

DISEASES OE THE CIRCULATOEY SYSTEM. 



CHAPTER L 

CYANOSIS. 

Certain of the diseases which pertain to the circulatory system have 
been treated of in other parts of this book (umbilical haemorrhage, gastro- 
intestinal haemorrhage, etc.). It remains to consider that general condi- 
tion of the blood which is designated morbus caeruleus or cyanosis. 

In 1863, I read before the New York Academy of Medicine a statistical 
paper on cyanosis, which was published in the Transactions of that Society. 
This paper contains an analysis of 191 cases, collated from the various 
European and American medical journals, and to these cases I am indebted 
for most of the following facts pertaining to this disease. 

The term cyanosis or blue disease is differently employed by writers. 
Some apply it to cases of transient lividity occurring in the course of acute 
diseases, as well as to those cases which depend on permanent structural 
changes, or on malformations. I apply this term, as do most pathologists, 
only to the latter cases. 

Some are inclined to discard the consideration of cyanosis as a disease, 
regarding it rather as a symptom. Their view is, in my opinion, correct 
in reference to the cyanotic state which occurs in certain acute diseases, 
but not in reference to cyanosis, as I have defined the term and employ it. 
The propriety of considering cyanosis a disease is more apparent if we are 
not misled by the term which designates it. Lividity is not its most im- 
portant or its essential characteristic. It is simply a sign, although con- 
spicuous, and, indeed, the only one by which the disease can be readily 
recognized. Cyanosis is, in reality, a blood dis-ease, its pathological state 
consisting in a deficient oxygenation of this fluid, or in an excess in it of 
carbonic acid, and probably of carbonaceous products. It should be placed 
in the same category with leucocythseraia and melanaiinia. 

Statistics show that cyanosis is, with very few exceptions, due to malfor- 
mation in the circulatory .system, and at the centre of circulation, namely, 



684 CYANOSIS. 

in the heart and in the large ve.-^sels which arise from tliis organ. In ex- 
ceptional cases? the cause of the cyanosis is located in the lungs, and is 
in all or nearly all instances either extensive emphysema in both lungs, 
firm and thick fibrinous exudation over both lungs, compressing them by 
its contraction and causing, perhaps, carnification in parts of them, or the 
cause is compression of the lungs from caries of the vertebrse, and conse- 
quent depression of the ribs. These causes pertain to youth and manhood 
rather than to infancy and childhood. On account of this fact and the 
rarity of such cases they need not be considered in this connection. 

Literature of Cyanosis. 

The ancient physicians, so far as can be ascertained from their writings 
still extant, were ignorant of cyanosis; whether they overlooked it, or 
whether those early ages were exempt from it and the malformation on 
which it depends is peculiar to a posterity physically degenerate. The 
blue disease described by Hippocrates {De Morhis, lib. ii, sec. v, page 485, 
Ed. de Foe's, 1621) was probably some acute febrile affection. Galen, 
whose voluminous writings, with an excellent index, are still extant, and 
whose comprehensive mind embraced the whole range of medical science 
of the second century, makes no mention of it, so far as I can find. In 
the middle ages, as appears from a remark of Boerhaave {Diseases of the 
Humors, Acad. Lect., § 732), the common people believed the cyanotic to 
be the victims of evil spirits ; and it is probable that physicians, during 
this long period of superstition and intellectual lethargy, embraced the 
popular belief. 

On the revival of learning, pathological anatomy began to be more 
thoroughly and intelligently studied ; but it is evident that before the 
great discovery of Harvey, in the 17th century, it was impossible to refer 
cyanosis to its true cause. In the latter part of the century so auspiciously 
opened by Harvey's genius, malformations of the heart were observed and 
described by some pathologists on the continent, in cases in which cyanosis 
must have been present; but it is uncertain, from the brief records w^hich 
they have left, whether any of them understood the dependence of this 
disease on the abnormal state of the heart. Boerhaave, in the beginning 
of the 18th century, attributes "a livid or black color diffused throughout 
the whole skin," evidently referring to cyanosis, to " 1, a relaxation of the 
vessels, while the vis a iergo remains the same, or, 2, to a too sudden 
increased pressure behind, without a relaxation of the vessels." Vieus- 
sens, who was a contemporary of Boerhaave, and was more thorough in 
the examination of morbid as well as healthy structures, narrated the 
history of a cyanotic patient, with a description of the malformation, but 
the one who first gave particular attention to the blue disease w'as Mor- 
gagni. This Paduan professor, far excelling his predecessors in thorough- 



LITERATURE OF CYANOSIS. 685 

ness of observation and accuracy of deduction, published a theory in 
explanation of the disease which now, after the lapse of more than a 
century, has many adherents. In the same century with Morgagni, the 
18th, but subsequently to his time, Drs. Pulteney, Wm, Hunter, Baillie, 
Wilson, and Abernethy in Great Britain, and Jurine and Sandifort on 
the continent, may be mentioned among those who contributed to a knowl- 
edge of cyanosis by the publication of cases, with a description of the mal- 
formations. Yet, when the present century commenced, no monograph 
or dissertation had appeared on this disease ; and, notwithstanding the 
publication of cases from time to time, the profession generally were 
almost totally unacquainted with its nature. No better idea can be given 
of the prevailing ignorance, in reference to cyanosis at this period, than 
by quoting from a case related by Eibes in 1814. {Bull de la Fac. de 
Med., 1815.) The patient had some time previously received an injury 
of the finger. " Many physicians of Amsterdam," says he, " were at dif- 
ferent times consulted on the subject of this affection, no one of whom 
understood its true cause, its essential character. One considered it as 
partaking of the nature of epilepsy, and caused by the irritation in the 
nervous system which the wound in the finger had produced. Others 
attributed it to the presence of intestinal worms. Some physicians pro- 
nounced it an injury of the liver or spleen. Many held it to be a scor- 
butic affection. One only believed it to be the result of an unknown 
organic disease." 

Since the commencement of the present century the blue disease has 
received a large share of attention, i^ccording to Forhes's Medical Biog- 
7X(phy, the first dissertation on this subject appeared in 1805, from the pen 
of Seller, and from this time till 1832 no fewer than twenty-eight disser- 
tations or monographs were published, either on cyanosis or on malforma- 
tions which produce it or at least relate to it. In the list of writers are 
some of the most eminent names in the profession, as Louis and Bouil- 
laud. The number who have written on this subject since 1832 probably 
exceeds the number of previous writers. Of those who have contributed 
most to our knowledge of the disease may be mentioned Farre, Chevers, 
and Peacock in Great Britain, Gintrac on the continent, and Moreton 
Stille in this country. Farre, Chevers, and Peacock wrote on malforma- 
tions of the heart, alluding incidentally to cyanosis, but their writings 
contain valuable matter for statistics bearing on the latter subject. 
Farre's book was published in 1814, and is out of print; Chevers pub- 
lished his papers in the London Med. Gazette, commencing in the year 
1845 and running through sevei-al successive volumes. Peacock's treatise 
was published in 1858. It contains several original cases, previously nar- 
rated by him to the London Pathological Society. The paper by Moretou 
Stille, which has attracted mucli attention, especially in Europe, was his 
inaugural thesis, and was published in the Amer. Med. Jour, of Med. Sci., 



686 CYANOSIS. 

in 1844. This paper relates entirely, in tlie words of the author, to "the 
laws of the causatiou of cyanosis." The only really complete statistical 
paper on the blue disease is that by M. Gintrac, published in 1824, in 
Paris, and embracing all the cases which had been accurately reported up 
to that time, namely, fifty-three. He, indeed, exhausted the subject for 
the period in which he wrote, but on account of the accumulation of ma- 
terial since, his monograph now seems incomplete. 

Two theories in explanation of the occurrence of cyanosis have divided 
the profession ; the one attributing it to obstruction at the centre of circu- 
lation, and consequent venous congestion ; the other, to admixture of venous 
and arterial blood through openings in the septa of the heart, or through 
the ductus arteriosus. The former of these theories originated with Mor- 
gagni more than one hundred years ago, and is essentially the same as that 
advocated by Stille. Stille errs in placing Morgagni among the advocates 
of the other system. The second theory, or that which attributes cyanosis 
to admixture of venous and arterial blood, is said by Dr. Peacock to have 
originated with Hunter, but its ablest supporter w'as Gintrac. Of late there 
are some pathologists who do not believe that either theory is sufficient to 
explain the cause of cyanosis, but that the true explanation lies somewhere 
between the two. Among the most conspicuous of these is Prof Walshe, 
of London. These theories will be considered in the proper places. 

Sex. — Writers on cyanosis state that there is a preponderance of males 
to females affected with it. Aberle, of Vienna, says that two-thirds were 
males in an aggregate of 180 cases which he collated. In Gintrac's cases, 
28 were males and 16 females; in Stille's, 41 were males and 31 females. 
The sex is recorded in 134 of the cases collected by me, of which 78 were 
males, 56 females ; and if those cases are excluded in which cyanosis was 
due to obstruction at the mouth of the pulmonary artery, the number of 
the two sexes is the same. In the five years commencing with 1858, ac- 
cording to the mortuary returns, 207 died in this city from cyanosis, of 
which number 117 were males, 90 females. In England, for two years, 418 
males died of cyanosis, and 273 females. Although statistics of different 
cities and countries agree in the fact of an excess of males over females, 
there does not appear to be that great preponderance of males, which the 
earlier writers on this disease believed to exist. 

Causes of the Malformations. — Mothers sometimes attribute the 
malformations, and probably correctly, to strong mental impressions felt 
during utero-gestation. The mother of a patient treated by Dr. Peacock 
stated that, "two months before her confinement, she was frightened by 
seeing a child killed, and never recovered from the shock she sustained." 
(Malf. of Heart, p. 37.) In another case " the mother was much out of 
health, and stated that, when pregnant with the child, she was greatly 
alarmed by seeing a man who was dying of asthma." (Op. cit., page 57.) 
In another instance the mother was frightened at the fifth month of preg- 



CAUSES OF THE MALFORMATIONS. 687 

nancy (page 41) ; and in still another case, recorded by Dr. Peacock, the 
mother, four or five months before her confinement, " was greatly alarmed 
by her husband, who was insane, standing over her for two hours with a 
loaded pistol." (Page 43.) 

Occasionally the malformation appears to be due to some vice or taint 
in the system of one or both parents. In a case quoted in the Gazette Mkli- 
cale, for December 28th, 1850, from another continental journal, it is stated 
that " the mother, who had formerly suffered from rickets, give birth to 
five children, all of whom died immediately or shortly after birth with symp- 
toms of cyanosis. The father died at the age of thirty -six of phthisis." Dr. 
Peacock relates a case in which the father was livid, and had the " pigeon- 
breast " common in the cyanotic. In the history of a patient, which was 
communicated by Cooper to Farre, it is related that " vices of conforma- 
tion of the heart appeared to have been inherent in the family. Of 
12 infants only 4 survived, and more presented signs of heart disease." 
Dr. Buchanan relates the history of a child which was the second that 
had suffered and died in the same family in the same way. A patient 
treated by Mr. Leonard was the sixth child of the family, who had died at 
about the same age, with symptoms of cyanosis. Such instances are, how- 
ever, exceptional. Ordinarily, the cyanotic have not only healthy parents 
but healthy brothers and sisters. 

A patient whose history is given by Dr. AVilliam Hunter was born at 
the eighth month, but in nearly all other cases the full period of uterine 
existence was reached. 

The opinion was expi'essed by Gintrac that the number affected with 
cyanosis, to the entire population, varies in different countries. It is prob- 
able that the occurrence of the blue disease is not greatly, if at all, influ- 
enced by the nationality, but it is certainly dependent to a considerable 
extent on the condition of society. It is less frequent in a community in 
comfortable circumstances, and engaged in wholesome and quiet occupa- 
tions. Pure air and outdoor exercise, plain, nutritious diet, freedom from 
cares and anxieties, in fine, causes which promote the physical well-being, 
diminish the liability to an ill-formed and cyanotic offspring. And, con- 
versely, impure air, improper and insufficient diet, grief, etc., increase the 
percentage of cyanotic cases. Hence, it is a rare disease in the rural dis- 
tricts, and comparatively frequent in the cities, especially in a large city 
like New York, which contains a numerous indigent and careworn popu- 
lation, living from year to year in the midst of agencies which operate 
stealthily but certainly to enervate the system and undermine the health. 

These remarks are abundantly substantiated by statistics. In New York 
City for the six years ending with 1860, there Avas one death from cyanosis 
to 436 deaths from all causes ; and in Brooklyn the proportion estimated 
for two years was about the same. On the other hand, in the State of Ken- 
tucky, which contains few large cities, and in the death reports of which 



688 CYANOSIS. 

cyanosis is included in tlie general term nialiorniation, there was, during 
a period of five years, one death from malformation to 2469 from all causes. 
In the State of South Carolina, for three years, there was one death from 
cyanosis to 5018 from all causes. In the State of Massachusetts, for two 
years, there was one death from cyanosis to 1136 from all causes, and two- 
thirds of the cyanotic cases occurred in the counties of Suflblk, Essex, and 
Worcester, which contain large cities. In London there was one death 
from cyanosis to 755 from all causes during a period of three years. On 
the other hand, in England, including the city of London, there was, for 
the ten years ending with 1857, one death from cyanosis to 1589 from all 
causes; and in the rural districts of Monmouth and Wales there was only 
one death from cyanosis to 5578 deaths from all causes during a period of 
two years. 

Time of Commencement. — It is an interesting and somewhat remark- 
able fact that cyanosis, though dependent on a malformation, does not al- 
Avays commence at birth, or, at least, that it does not exist in degree suffi- 
cient to produce the cyanotic hue till some time has elapsed after birth. 
In 138 of the cases of cyanosis which I have collected, the time at which 
lividity was first observed is stated as follows : In 97 it was within the first 
week, and generally within a few hours of birth. In the remaining 41 
cases it commenced as follows : 

In 3 at 2 weeks. In 6 from 2 years to 5 years. 

" 1 " 3 " " 1 " 5" " " 10 " 

" 2 " 1 month. " 6 " 10 " " 20 " 

" 7 from 1 to 2 months. " 1 " 20 " " 40 " 

" .5 " 2 " 6 '' " 1 over 40 years. 

" 5 " G "12 " — 

"3 " 1 year to 2 years. 41 

In these 41 cases, in which blueness did not occur till after the age of 
one week, if the patient were less than two years old when it commenced, 
there was frequently no obvious exciting cause, but above this age, with 
three exceptions, such a cause is known to have been present. It is in- 
teresting to observe how trivial the exciting cause frequently is, and equally 
interesting to note how long patients have enjoyed good health, not having 
the least lividity, although the anatomical vice, to which the final develop- 
ment of c3'anosis was due, had existed from birth. 

Dr. Theophilus Thompson relates, in the Medico- Chir. Trans., vol. xxv, 
the history of a lady, thirty-eight years old, who was well till an attack of 
Asiatic cholera, after which her health was permanently impaired. Two 
years before her death she passed through a course of fever, and from this 
time was cyanotic. In the Fhiladeljihia Medical Examiner, June, 1850, Dr. 
Waters relates a case, in which cyanosis began at the age of six years in 
an attack of measles. In a case published by Mr. Napper, in the London 
Medical Gazette, 1841, the child fell at the age of six months, and from 



SYMPTOMS. t)»y 

this time had cyanosis. A female, whose history is given by Prof. Tom- 
masini, of Bologna, and quoted by Bouillaud, became cyanotic at the age 
of twenty-five in consequence of difficult parturition. In the London 
Lancet, 1842, Mr. Stedman relates a case, in which cyanosis began at the 
age of ten weeks in an attack of convulsions. In the American Journal of 
Medical Sciences, 1847, Dr. John P. Harrison published the history of a 
baker, twenty years old, in whom cyanosis began five years previously after 
great effort in carrying wood. Louis and Bouillaud quote from M. Oaillot 
the case of a child, who became cyanotic at the age of two months in an 
attack of hooping-cough. Louis also narrates a case in which hooping- 
cough had the same effect at the age of twelve years. Ribes treated a child 
in whom the blue disease began at the age of three years from a severe 
contusion of the fingers. In a case related by Marx it commenced at the 
age of ten months from a blow on the back, inflicted by the mother. In 
the Medical Times and Gazette, for 1855, Mr. Speer gives the history of a 
female, who at the age of thirteen years was put in a place requiring con- 
siderable exertion, and from this time was cyanotic. A patient, whose case 
is related by Cherrier, fell into a deep ditch in the winter season, and im- 
mediately after had a low fever, from which the blue disease commenced. 
In a case published by Taccouus the exciting cause was believed to be 
fright, in consequence of a fall from a great height, and in another, related 
by Bouillaud, it was a blow received on the epigastrium after the patient 
had passed the age of fifty years. Similar cases are related by Mayo and 
Peacock. 

It will be seen that the exciting cause of cyanosis is usually such as pro- 
duces a profound impression on the system, and affects the action of the 
heart. Precisely in what way it operates to develop the disease has not 
been satisfactorily explained. Mr. Mayo conjectures, that in the case re- 
lated by him there was previously some compensation which ceased, or be- 
came inadequate in consequence of some change produced in the economy. 
Although cyanosis may not appear for months or even years, there is rarely 
improvement when it is once established. Appearances of amendment are 
deceptive. The disease when not stationary is progressive, and this ex- 
plains the fact, that few survive the middle period of life. 

Symptoms. — The symptoms of cyanosis vary in intensity in different 
patients, and in the same patient at different times, being milder if he is 
quiet and the mind calm, more severe if active, or if the mind is agitated. 
In mild cases, in a state of rest, they nearly or quite disappear, so that a 
stranger would not suspect that there was any serious ailment. They are 
aggravated by any cause which accelerates the action of the heart. In 
some, cyanosis is increased by the most trivial disturbing influences, 
among which may be mentioned nursing, dentition, crying, coughing, and 
slight emotions of joy, sorrow, or auger. In more than one case it has 

44 



G90 CYANOSIS. 

been perceptibly increased by the stimulus of digestion, the color being 
deeper after a full meal than before. 

The cyanotic hue varies iu different individuals from duskiness to a 
deep purple, almost black color. It is usually most marked in the visage, 
especially the palpebral, cheeks, nose, and lips, in the ears, fingers, and toes, 
and upon the mucous surfaces. It is sometimes, without any assignable 
cause, confined to a portion of the body. In a case related by Mr. Steel 
in the London Lancet, 1838, the upper part of the body was livid and 
oedematous, and the lower part pallid and shrunken, and yet the malfor- 
mation was of the kind which is commonly present in cyanosis. In the Lon- 
don Medical Times, March 8th, 1845, copied from the Gazette Mcdicale, is 
the history of a child six years old, in whom the color was deeper on the 
right than left side. There had been, however, hemiplegia of this side in 
infancy, but this had entirely passed off. On the other baud, in a case of 
rare malformation communicated by Cooper to Farre, in which the upper 
part of the system was supplied chiefly by arterial and the lower by venous 
blood, the discoloration was general. In exceptional instances livid maculae, 
like those of purpura, have been observed upon the skin. 

Those affected with cyanosis have generally at birth been well formed 
and of the usual size, and in most cases, for a considerable period after 
birth, the appetite is good, bowels regular, and the system well nourished. 
But when cyanosis becomes so severe, as it does sooner or later, that its 
symptoms are rarely absent, digestion is imperfectly performed, and the 
bodv becomes either emaciated or stunted and puny. It may be stated, 
as a rule, that nutrition is in inverse proportion to the gravity of cyanosis. 
In thirty-three out of forty-one cases, in which the condition of the system, 
as regards nutrition, was recorded either a short time previously to death 
or at the autopsy, the body was either considerably emaciated or else 
diminutive, and those who were well nourished were usually such as had 
died early, or of some intercurrent disease. 

In this connection may be mentioned two abnormalities which have been 
observed in the cyanotic. The chest is often flattened laterally with a pro- 
jecting sternum, so as to present an appearance generally described in the 
records as " pigeon-breasted." Sometimes the most prominent part is di- 
rectlv over the heart, and in one or two cases the sternum was observed to 
be deflected towards the left. In the majority of the records, however, no 
mention is made of the external appearance of the chest. 

The other abnormal development is more remarkable, and has not been 
satisfactorily explained. In twenty-eight cases it is stated that the tips of 
the fingers or toes, or both, were bulbous. This hypertrophy, if slight, is 
likely to be overlooked, and that it was observed and recorded in so many 
cases renders it probable that it was present in a much larger number. In 
one case the anatomical character of this enlargement was examined, and 



SYMPTOMS. 691 

was found to consist chiefly of hypertrophied connective tissue. The nails 
are often incurvated over the deformity. At a meeting of the Lond. Path. 
Soc, in 1859, Mr. Ogle narrated the history of a laborer, fifty years old, 
who had swelling, numbness, and lividity of the left arm, from pressure of 
an aneurism, and the fingei's on this side were clubbed as in cyanosis. A 
patient whose history is related in the Glasgow Medical Journal, and who 
was believed to be cyanotic in consequence of a highly emphysematous state 
of the lungs, had a similar development of the tips of both fingers and toes. 
Why this bulbous growth should occur in consequence of the circulation of 
non-oxygenated blood is unknown. 

An interesting feature in cyanosis is the low grade of animal heat. The 
temperature of the body is in all cases below that of health. This is es- 
pecially noticeable in the extremities. There has not been a sufficient 
number of accurate thermometric observations to determine whether the 
internal heat is usually reduced. The following only have been recorded : 
Mr. Fletcher relates the history of a young man in the Medico-Chir. Trans., 
vol. XXV, in whom the thermometer placed in the mouth did not stand above 
80° Fahrenheit. Hodgson reports the case of a man, twenty-five years old, 
in whom the thermometer placed on the tongue rose to 100°, while in his 
own case it was two or three degrees below that term. In an experiment, 
recorded by Nasse, the instrument placed in the mouth fell little if at all 
below the healthy standard ; applied to external parts, it stood at about 
21° Reaumur. 

The lack of heat is the source of great discomfort to a cyanotic patient. 
In mild weather he requires a fire to keep him warm, or an amount of 
clothing which to others would be intolerable, and in cold weather slight 
exposui-e strikes him with a chill. Nor can he increase his heat by active 
exercise, since his infirmity disqualifies him for this. 

Although the temperature of the surface is so low, the occurrence of 
perspiration, sometimes profuse, is mentioned in several of the' records. 

In severe cases of cyanosis the generative system is imperfectly de- 
veloped. In the female, menstruation is scanty or delayed, and in the 
male signs of puberty are feebly manifest. If the disease is so mild that 
the symptoms are absent when the patient is in a state of repose, these 
organs attain nearly or quite their normal development. The catamenia 
have appeared as early as the age of sixteen years ; and a cyanotic patient 
treated by Cherrier had two children, but they both died of scrofulous 
affections. 

The action of the lieart is necessarily much affected. In mild forms of 
the disease, if the patient is quiet, this organ may beat with considerable 
slowness and regularity, but in all cases exercise or excitement, which in 
a state of health would scarcely have any appreciable effect on the pulse, 
embarrasses its movements, and produces palpitation. In severe cases 



692 CYANOSIS. 

palpitation is rarely absent, and the pulse is frequent, feeble, and often 
intermittent. In a large proportion of patients bruits are produced by 
the irregular circulation through the heart. 

The respiration corresponds with the action of the heart. It is accelerated 
in proportion to the frequency of the pulse. The suffering in this disease 
is largely due to paroxysms of palpitation and dyspnoea. These occur 
sometimes without any apparent exciting cause, and when the patient is 
quiet, but they are commonly induced by those causes which we have al- 
ready mentioned as aggravating tlie symptoms of cyanosis. They come 
on suddenly, and are attended by increase of lividity, distension of the 
jugulars, and sometimes of the cutaneous veins, and by a sensation of 
present suffocation. They last only a few minutes, and are succeeded by 
great depression of the vital powers. In infants, on account of greater 
nervous irritability, and feeble power of endurance, these paroxysms 
generally end in convulsions, which occasionally are fatal. A cough is 
sometimes present, but it is usually slight. 

Pain is not a common symptom. Some of the patients complained 
occasionally of headache, with or without vertigo, and occasionally also 
of jxiin in the chest, but it is uncertain to what extent or whether these 
symptoms were dependent on the cyanotic disease. The secretions do not 
appear to be affected, so far as has been ascertained. The same may be 
said of the intellectual and moral faculties. In a case related by Dr. 
Chevers, the child was even said to be precocious. (Lond. Med. Gaz., vol. 
xxxviii.) The mind is capable of steady application and acquisition, as 
in health, provided that the emotions are not unduly excited. 

Those who are affected with cyanosis are liable to various forms of haem- 
orrhage, but this liability, if we may judge from recorded cases, is greater 
in youth and adult life than in infancy. In two cases blood was vomited, 
in one passed by stool, in one it escaped from the gums, in two from the 
mouth, in eight from the nostrils, and in sixteen it was expectorated. 
Pulmonary phthisis was, however, usually present in these last cases. In 
the Western Journal of Medicine for 1829, an interesting case is related by 
Dr. Wm. M. Voris of a girl, nine years old, in whom haemorrhage occurred 
under the scalp, producing great tumefaction, and nearly closing the e3^e- 
tids. An incision was made, from which a pint and a half of dark blood 
escai:)ed, and it was estimated that more than half a gallon was lost during 
the ensuing two weeks, at the expiration of which time the incision closed. 
The })atient recovered from the haemorrhage but not from the cyanosis. 

Towards the close of life there is occasionally more or less anasarca, 
especially around the ankles, sometimes in the eyelids and fjice, and rarely 
to a certain extent over the whole body. In certain patients it coexists 
with effusion in the serous cavities. 

It is evident that one who is affected with the severer form of cyanosis 



PEOGNOSIS. 693 

is disqualified for the duties of active life. The sports of childhood and 
the useful labors of matqre years require an exertion for which he is physi- 
cally unfit. He has not the ability even to engage in animated conver- 
sation, for he is overcome by emotions, whether of joy or sorrow. He lives 
almost an idle spectator of the world around him, prevented by his infir- 
mity from engagiug in its pursuits. 

Intercurrent diseases, especially those of childhood, are badly tolerated ; 
but hooping-cough is the one which these patients are especially ill-fitted 
to endure. Still, they sometimes pass safely, not only through hooping- 
cough, but through some of the most dangerous febrile diseases. It is a 
question of interest, but about which little is known with certainty, whether 
these intercurrent maladies are influenced by the cyanotic or venous con- 
dition of the blood. The symptoms of these maladies are no doubt more 
alarming, mainly on account of the embarrassed action of the heart, and 
not on account of the state of the blood ; still it is reasonable to suppose 
that malignant and asthenic diseases are rendered w-orse by the lack of 
oxygen, and excess of carbonic acid in the circulating fluid. 

Probably cyanosis does not furnish immunity from any other disease, 
although this statement has been made by a high authority. Rokitansky 
says : "All forms of cyanosis, or rather all the diseases of the heart, great ves- 
sels, and lungs adapted to j^roduee eyanosis, in a greater or less degree, cannot 
coexist with tuhercidosis. Cyanosis affords a complete protection against it, 
and in this circumstance may be found an explanation of the immunity from 
tuberculosis tvhich many conditions of the system, apparently very different in 
their character, afford." (Handb. der. Pathol. Anat., II. Bd.) This opinion 
of the distinguished pathologist, notwithstanding his ample opportunities 
for observation and known accuracy as an observer, is not substantiated 
by statistics. So far from its being true, the low degree of vitality in cyan- 
osis appears to favor the occurrence of tubercles. I have records of twenty- 
six cases of cyanosis in which tuberculosis was also present, in several of 
which the lungs contained cavities. This is about thirteen per cent, of the 
whole number in my collection — a large proportion, since so many die in 
early infancy, at which period the tubercular disease is not apt to occur. 
Cyanosis appears, also, to favor the development of cerebral diseases, es- 
pecially congestion and coma, as will be seen presently. 

Prognosis. — This is unfavorable. Most cyanotic individuals die young. 
The age which they attain has been made the subject of statistical inquiry 
by Aberle. He states that in an aggregate of 159 cases, 57, or 35 per cent., 
died before the end of the first year; 108, or more than two-thirds, died 
before the age of eleven years; 30 between the ages of 11 and 25 years; 
and of the remaining 21, five only lived more than 45 years. 

The age at which death occurred is given in 186 of the cases collected 
by myself, as follows; 



12 ' 


' 1 month to 3 months. 


11 ' 


' 3 months to 6 months. 


17 ' 


' G " to 12 " 


12 ' 


' 1 year to 2 years. 


21 ' 


' 2 years to 5 " 



694 CYANOSIS. 

In 17 under the age of 1 week. In 21 from 5 years to 10 years. 

" 10 from 1 week to 1 month. " 41 " 10 " " 20 " 

" 20 " 20 " " 40 " 
" 4 over 40 " 

186 



Sixty-seveu, then, or more than one-third, died before the close of the 
first year ; 121, or more than three-fifths, before the age of ten years ; only 
24 survived the age of twenty years, and four the age of forty years. Of 
course, the duration of life depends on the nature and extent of the mal- 
formations. Some of these are such as render a speedy death inevitable. 

Mode of Death. — The mode of death is recorded in ninety-five cases, 
as follows : 

19 died in a paroxysm of dyspna?a. 

10 " suddenly (the exact manner not stated). 

14 " in convulsions (infants). 
2 " of apoplexy. 
7 " from haemorrhage. 
6 " of phthisis (though, as we have seen, twenty others had this 

disease). 
2 '' of exhaustion, without hceraorrhage. 

10 " of coma. 
2 " of abscesses in the brain. 

1 died of each of the following diseases : cerebral irritation, congestion 
of brain, eff'usion in the cranial cavity, acute hydrocephalus, paralysis 
from acute softening of the brain, dysentery, inflammation of heart, syn- 
cope, mucus in the air-passages, thoracic inflammation, choleraic diarrhoea, 
pneumonitis, bronchitis, scarlet fever, croup. One died in trying to walk, 
one after a spasmodic cough in pertussis, one after a long agony, one after 
an agony of ten or eleven hours ; one is recorded to have died gradually, 
and three quietly. 

The ten who are stated to have died suddenly probably died in parox- 
ysms of palpitation and dyspnoea, which, we have seen, are easily excited, 
and of common occurrence in cyanosis. If so, this was the mode of death 
in 29 cases. Infants, with few exceptions, so far as appears from the 
records, died in convulsions. Nineteen died of cerebral affections, ex- 
clusive of convulsions, and in thirteen of these the cause of death was 
congestion, apoplexy, or coma. The hsemorrhage of which seven died 
was probably, in most instances, dependent on phthisis, and six are said 
to have died directly of phthisis. We may, then, regard paroxysms of 
palpitation and dyspnoea, convulsions, congestive affections of the brain, 
and phthisis, as common modes or causes of death in cyanosis. 

The malformations of the heart and great vessels which give rise to 



MODE OF DEATH. 695 

cyanosis are quite numerous. The following table exhibits their char- 
acter and relative frequency : 

Cases. 

1. Pulmonary artery absent, rudimentary, impervious, or partially obstructed, 97 

2. Eight auriculo-ventricular orifice impervious or contracted, ... 5 

3. Orifice of the pulmonary artery, and the right auriculo-ventricular aper- 

ture impervious or contracted, ........ 6 

4. Right ventricle divided into two cavities by a supernumerary septum, . 11 

5. One auricle and one ventricle, ......... 12 

6. Two auricles and one ventricle, 4 

7. A single auriculo-ventricular opening: inter-auricular and inter- ventric- 

ular septa incomplete, .......... 1 

8. Mitral orifice closed or contracted, ........ 3 

9. Aorta absent, rudimentary, impervious, or partially obstructed, . . 3 

10. Aortic and the left auriculo-ventricular orifices impervious or contracted, 1 

11. Aorta and pulmonary artery transposed, ....... 14 

12. The cavse entering the left auricle, 1 

18. Pulmonary veins opening into the right auricle or into the cavie or azygos 

veins, ............. 2 

14. Aorta impervious or contracted above its point of union with the ductus 
arteriosus; pulmonary artery wliolly or in part supp]3'ing blood to the 
descending aorta through the ductus arteriosus, 2 

Total, 164 

From the above table it appears that in more than one-half of the cases 
of cyanosis the congenital vice which gives rise to it is located in the pul- 
monar}^ artery. It is located also, in general, in that part of the artery 
which is nearest the heart. Its character is different in different cases. 
Sometimes there is an arrested development of this vessel, and in its place 
we find simply a ligamentous cord extending from the heart as far as the 
ductus arteriosus, while beyond this point the artery and its branches are 
pervious ; rarely the entire artery is ligamentous and, of course, impervi- 
ous ; in other cases this vessel is open through its whole extent, but the 
part nearest the heart is so small as to be properly considered rudiment- 
ary ; in others still there is adhesion of the valves to each other as the 
chief congenital defect, and, finally, in rare instances the obstx'uction in 
the pulmonary artery is due to an adventitious membrane, which stretches 
across the vessel like a diaphragm. These last malformations, namely, 
adhesion of the valves and the formation of an adventitious membrane, 
are, doubtless, due to inflammation occurring in the artery before birth, 
and some attribute the arrested development and ligamentous state of the 
vessel to the same cause. 

In most cases of cyauosi.s, due to obstructive malformations, there is 
deficiency in the inter-auricular and inter-ventricular septa. This defi- 
ciency obviously results from the obstruction, for the septa are formed in 
the heart after foetal circulation is established, and the blood, being pre- 



696 CYANOSIS. 

vented by the vicious formation from flowing in its proper channel, neces- 
sarily passes to the opposite side of the heart. More or less blood being 
forced from one auricle or one ventricle to the opposite cavity, it is evi- 
dent that a permanent aperture must result in the septum. The aperture 
in the septum ventriculorum is ordinarily at its base; in the septum auric- 
ulorum it corresponds with the foramen ovale. 

In most of the obstructive malformations one and rarely two abnormal 
cardiac murmurs have been observed. The single murmur accompanies 
the ventricular contraction. As it has been observed in cases of complete 
as well as incomplete obstruction, it seems to be due mainly to the flow of 
blood through the apertures in the septa. 

Modes of Compensation. — In most cases of cyanosis, the congenital 
defect is partially obviated by modes of compensation. In the most fre- 
quent malformation, that in which there is obstruction in the pulmonary 
artery, and a considerable part if not all the blood flows directly from the 
right to the left side of the heart, the ductus arteriosus not only remains 
open, but is greatly enlarged, through which a current of blood enters the 
pulmonary artery from the aorta, and passing to the lungs is oxygenated. 
The bronchial arteries have also been found greatly enlarged, and it is 
believed that though they are the nutrient arteries of the lungs, the blood 
which they convey to these organs is decai'bonized in its circuit through 
them. In a case published by Mr. Le Gros Clark, in the MecUco-Chir. 
Trans., vol. xxx, the bronchial arteries were not only enlarged, but a 
"branch from the internal mammary artery, which accompanied the 
phrenic nerve, was nearly equal in size to the parent trunk, and expended 
itself principally in the adjacent adherent lung." Branches of the inter- 
costal arteries have also been found enlarged, and entering the lungs, or 
connecting with vessels which entered the lungs. By such modes of com- 
pensation cyanosis is rendered milder, and life is prolonged. To these we 
must attribute the fact that some have very considerable malformation, 
and yet do not become cyanotic. 

Morbid Anatomy. — This, as regards the circulatory system, has been 
sufiiciently dwelt upon. No chemical analysis, so far as I am aware, has 
yet been made of cyanotic blood. We know that it is dark, its coagula- 
bility feeble, that it contains an excess of carbonic acid, and is deficient 
in oxygen. From the nature of cyanosis, it would be inferred that in 
many cases there is a degree of passive congestion in the cavities of the 
heart, and consequently in the capillaries of the systemic system, giving 
rise to more or less serous effusion. Statistics show that this is so. The 
quantity of pei'icardial fluid is in some patients increased. I have records 
relating to this fluid in fifty-one cases. Usually it was pure serum. In 
seventeen the quantity was half an ounce or less, if we include in the num- 
ber those in which the amount is expressed in such terms as " due quan- 
tity," " unusual amount," and " small amount." In twenty-four cases 



THEORIES RELATING TO ETIOLOGY OF CYANOSIS. 697 

the serum exceeded half an ounce ; usually estimated at from one to six 
ounces, but in two it exceeded the latter quantity. In one of the twenty- 
four the serum was sanguinolent. In two cases the records state that there 
■was a small quantity of blood in the pericardium, and in the remaining 
patient the two pericardial surfaces were agglutinated by inflammation. 

In some of the autopsies serum was found in the pleural cavities, usually 
in connection with pericardial effusion, and in at least one instance the 
serum was tinged with blood. Old adhesions between the costal and pul- 
monary pleura were observed in a few instances. The condition of the 
lungs was recorded with more or less minuteness in one hundred and ten 
eases. Mention has already been made of the large nuijiber affected with 
tubercular disease, which was either confined to the lungs, or was chiefly 
exhibited in these organs. In thirty-five patients the records state that 
the lungs were of small size, either by compression, or sometimes, appar- 
ently, by the continuance of the foetal state over a greater or less portion 
of the organ. The compression was produced either by the distended 
pericardium' or by effusion in the pleural cavities. In thirty-five cases the 
lungs presented a dark color. This hue in some specimens accompanied 
the unexpanded or foetal state of the organ, but in others there was the 
normal inflation, and the dark color was due to engorgement or conges- 
tion. In other cases the lungs are stated to have been natural, except the 
color. In nine there was emphysema in a part of the lungs, in two pneu- 
monitis ; in two the color was pale, in one a bright crimson ; in one the 
lungs were larger than natural, in one the right lung was absent, and in 
seventeen these organs were recorded healthy. 

I have records of the state of the liver in twenty-six cases, in sixteen of 
which it was enlarged, and in four of those enlarged it was congested. 
Congestion was present in eight other cases, in which no mention is made 
of the volume. The parenchyma had a natural appeai'ance in nine cases, 
but in some of these there was enlargement. From these statistics it is 
probable that the liver is commonly enlarged in cyanosis, and not infre- 
quently congested. In a few cases the condition of the other abdominal 
viscera is mentioned ; in some as healthy, in others as congested. There 
were fifteen examinations of the brain, in seven of which congestion is re- 
corded, and in three abscesses in the cerebral substance, in one of which 
cases the lateral ventricle was also filled with pus ; in two there was soften- 
ing of a portion of the brain, in three the brain was firm or compact, in 
three the quantity of fluid in the cranial cavity exceeded the normal 
amount, and in one it was less. 

Theories Kelating to the Etiology of Cyanosis. — Although in 
nearly all cyanotic patients there are direct communications between the 
two sides of the heart, it is shown by many observations that these com- 
munications or apertures are not sufficient in themselves to produce cyan- 
osis. This opinion was expressed half a century ago by Louis, who pub- 



698 CYANOSIS. 

lished an excellent monograph on the subject of these communications, 
basing his remarks on an analysis of twenty cases. Since the publication 
of this paper, the belief has been pretty general in the profession, and ob- 
servations continue to substantiate it, that, although the apertures may be 
of considerable size, if the two sides of the heart, with their orifices and 
vessels, are in their normal state, so that they act symmetrically and with- 
out obstruction, cyanosis will not occur. In proof of the correctness of 
this opinion many cases might be cited of a pervious, and some of a largely 
dilated foramen ovale Avithout the cyanotic hue, cases which have been 
published in the journals since the appearance of Louis's monograph. 
Still, in cases of obstructive malformation, unless the obstruction is com- 
plete, cyanosis is more apt to occur in consequence of these apertures, for 
were they absent a larger amount of blood would be propelled through 
the narrowed orifice, and a larger amount consequently be oxygenated. 

Allusion has already been made to the two theories which prevail in 
the profession ; the one attributing cyanosis to the intermingling of venous 
and arterial blood ; the other to obstruction at the centre of circulation, 
and consequent venous congestion. There are serious objections to the 
acceptance of either theory as an explanation for all cases. That admix- 
ture of the two kinds of blood is not essential to the production of cyanosis, 
is apparent from the following facts. In one case in the Fourth 3Ialforma- 
tion, there was no communication between the two sides of the heart, and 
the ductus arteriosus Avas closed, so that admixture was impossible. Again, 
in the Eleventh Malformation , or that in which the aorta and pulmonary 
artery are transposed, the blue disease evidently does not depend on the 
admixture of the tw'o currents. On the other hand, in this curious state 
of the heart, the more the admixture the less the cyanosis, since the only 
way in which the systemic current of blood can be arterialized is by passing 
to the opposite side of the heart. An argument against this doctrine may 
also be found in the fact that the modes of compensation are not such as 
in any way diminish or obviate the admixture. It is admitted that in the 
more frequent malformations cyanosis is increased by the apertures, which 
allow the intermingling of the venous and arterial currents, but it is more 
reasonable to consider the intermingling and the cyanosis as the direct re- 
sults of the malformation, neither having the precedence of the other, than 
to consider that they are related to each other as cause and eflTect, or as 
proximate and remote results. Viewed in this light, the admixture must 
be considered simply a concomitant of the cyanosis. 

The second theory, that of venous congestion, has numbered among its 
advocates many who have given special attention to the subject, as Mor- 
gagni, Louis, and Stille, but it seems to have even less claim for accept- 
ance than the theory of admixture. It has been seen that in nearly all 
cases of cyanosis the two sides of the heart communicate freely, so that if 
the current of blood meets with an obstruction, as it commonly does, it 



TREATMENT. • 699 

readily escapes to the opposite side where the artery is large and gives it 
free passage. In this way congestion, if not prevented, is greatly diminished. 
Again, it will be seen that, although certain of the viscera are frequently 
found at the autopsy more or less congested, congestion is not uniformly 
present in the organs, as it would probably be were it the proximate cause 
in all cases of cyanosis. 

Moreover, in some patients the malformation is not obstructive. The 
cavities and their orifices are of the normal size, and cyanosis is due en- 
tirely to malposition of the vessels. It cannot be said that in these cases 
there is venous congestion from arrest at the centre of circulation. If there 
is any congestion, it must be due to the fact that venous blood does not 
circulate as readily as the arterial in the capillaries. It is true that in 
the paroxysms of dyspnoea there is sometimes more or less congestion; the 
distension of the jugulars shows this, but it subsides with the paroxysms, 
and it probably is no more than usually occurs when the respiration is 
greatly embarrassed. 

In fine, attempts to express the immediate pathological state producing 
cyanosis in the terms of a general law have failed. However plausible 
the above theories may appear in regard to certain cases, there are others 
to which they are manifestly inapplicable. Those who advocate these 
theories seem to lose sight of the obvious fact that the chief want of the 
economy in cyanosis is arterialization of the blood, and it is hardly sup- 
posable that there can be any correct theory of its causation which is not 
founded on this fact. With this want of the economy in view it does not 
seem difficult to express a theory in comprehensive terms which is appli- 
cable to all cases, such as the following : Cyanosis is due to vices or defects 
in the organism, usually congenital, which prevent the free and regidar flow 
of blood to, through, or from the lungs. So comprehensive a statement in- 
cludes not only cases of malformation and malposition of the heart and its 
vessels, but also those few cases in which the lungs are in fault. In most 
patients, as we have seen, the current of blood toivards the lungs is ob- 
structed, and the current of blood from the lungs, in those comparatively 
rare cases in which the malformation is on the left side. 

Treatment. — From the nature of cyanosis it is evident that the treat- 
ment should be more hygienic than medicinal. The patient should be 
warmly clad and kept in a warm room, and all agencies calculated to 
embarrass or disturb the functions of the body or excite the emotions, and 
thereby accelerate the heart's action, should be studiously avoided. The 
diet should be nutritious, but simple and easily digested. 

Those who have attributed cyanosis wholly to apertures in the inter- 
auricular and inter-ventricular septa, and the consequent flow of blood 
from the right to the left side of the heart, have considered it an im- 
portant part of the treatment to keep the patient reclining on the right 
side, so as to diminish this flow by the effect of gravitation. The reader, 



700 CYANOSIS. 

however, must be convinced from the nature of the malformations that 
little benefit can accrue from following such advice. Still, patients are 
sometimes less cyanotic and more comfortable in one position than another. 
In a case reported by Mr. Howship (Edin. Med. Jour., 1813), " the only 
easy and indeed comfortable position in which the child could remain was 
that usual in nursing. When erect, the dusky color of the face and neck 
became a dark-blue." In a case i-elated by Mr. Spackraan {Lond. Med. 
Gaz., 1833), the patient was easiest on the hands and knees. Louis re- 
ports a case (de la Commun. des Cav., etc.) in which the selected position 
was with the head elevated ; Wra. Hunter a case {Med. Ohs. and Enq., 
vol. vi) in which the patient avoided paroxysms by lying on the left side. 
Struthers and King each reports a case in which the patients seemed most 
comfortable while lying on the right side {Monthly Jour, of Med. Sci.), 
while, on the other baud. Professor White, of Buffalo (Buf. Med. Jour., 
1855), and Dr. Jas. Carson (Amer. Jour, of Med. Sci., 1857), repoi't cases 
in which position on the right side failed to produce any alleviation of 
symptoms. Other similar observations might be cited, but enough have 
been mentioned to show that no one position should be recommended for 
cyanotic patients. Some obtain most relief by lying on the back, others 
on the right side, others on the left, some when on the hands and knees, 
some when reclining on either side indifferently, while, finally, others suffer 
least when erect. 

There was a time when the paroxysms were treated by venesection, 
but depletion has long since been abandoned. Physicians now rely on 
stimulants, antispasmodics, friction to the chest, and mustard pediluvia, to 
relieve the urgent symptoms, although this treatment is but partially suc- 
cessful. 



SECTION V. 

SKm DISEASES. 

CHAPTEE I. 

ERYTHEMATOUS DISEASES. 

Under this head are inehided erythema, roseola, and urticaria. They 
consist in an active congestion, inflammatory it is believed, of the skin, 
which soon declines, with or without slight furfuraceous desquamation. 
The color of the affected cuticle is a bright-red in erythema, rosy in roseola, 
and a pale-red in urticaria. Febrile symptoms often precede for a few 
hours the occurrence of the eruption, and abate as it appears. 

Erythema. 

The eruption of erythema occurs in patches of different sizes, the largest 
ordinarily not exceeding four or five inches in length, and most of them 
have considerably smaller dimensions, their margins being in some 
instances diffused, and in others cii'curascribed and well defined. The 
patches are slightly swollen from engorgement of the capillaries of the 
skin and slight serous effusion, and are accoaapanied by a sensation of 
heat and itching. 

Erythema is idiopathic or symptomatic. The idiopathie form is sub- 
divided into erythema simplex, intertrigo, and Igeve. Erythema simplex 
is produced by external agencies of an irritating nature, as heat, cold, 
friction, chemical and mechanical irritants, applied to the skin. A com- 
mon example of this form of the disease is the efllorescence about the 
anus in cases of infantile diarrhoea due to acidity of the evacuations. 
Erythema intertrigo is produced by the friction of opposing surfaces of 
the skin, and it therefore occurs mainly in the folds of the neck, about 
the groins, and behind the ears. This inflammation is sometimes slight, 
disappearing in two or three days with proper treatment ; in other cases 
the epidermis becomes denuded, the surface is tender and moist, and even 
superficial excoriations occur. In severe cases the ulcers extend more 
deeply and give rise to considerable purulent discharge, the skin and even 
subcutaneous connective tissue beiner more or less infiltrated and iudu- 



702 ERYTHEMA. 

rated. The confinement of the perspiration, and tlie moisture, which is 
exuded between the folds of the skin, increase the inflammation. The 
effused liqnid does not in ordinary cases stiffen linen, as in eczema. Ery- 
thema hove is tiie name applied to the inflammatory hyperemia of the 
skin, which often occurs over oedematous parts. Its most common seat is 
about the ankles and upon the legs. In children it is most freqnently 
observed in the (edema which results from scarlatinous nephritis and from 
heart disease. 

Symptomatic erythema, which results from a general or constitutional 
cause of a pyrexial character, has several subdivisions. The simplest and 
mildest form of it is erythema fugax, which comes and goes quickly. 
The erythema which occurs upon the features in acute meningitis is a 
typical example. It is common in various inflammatory and febrile af- 
fections. If the erythematous patch is circular, with normal skin in its 
centre, it is sometimes designated erythema circinatum, and, if the margin 
is well defined, marginatum. Erythema papulatum, tuberculatum, and 
nodosum are applied to the same form of the disease, one or the other 
term being employed according to the stage or size of the eruption. In 
erythema papulatum the eruption begins as small red spots, which soon 
become papular, and attain a size varying from thi^t of a pin's head to a 
split pea. It occurs especially on the neck, breast, arm, and back of the 
hand, and fades away, with a slight desquamation, in about three weeks. 
In erythema tuberculatum and nodosum the eruptions have a gr'eater 
diameter, and are usually more prominent. In the latter variety they 
often have a diameter of two or more inches, and occur most frequently 
upon the anterior aspect of the leg. These three forms of erythema, 
which might be described as one, occur chiefly in young people. Ery- 
thema tuberculatum is most common in servants, especially those recently 
from the country. The tumefaction is due to the effusion of serum in the 
corium, and, when the eruption has considerable prominence, also in the 
subcutaneous connective tissue. The color is at first a bright-red, then 
dark-red or purple, and it fades away like the discoloration of a bruise 
as the eruption declines. Rheumatism is often and diarrhoea occasionally 
associated with these forms of erythema, and rheumatic pains are occa- 
sionally present, as well as more or less febrile movement. 

Pr()(;nosi,s. — This as regards the erythema is always good. An unfa- 
vorable result in any case is due to cachexia, or some coexisting disease. 
The duration of the milder forms is only a few hours, while the .severer 
forms, as erythema nodosum, last two or three weeks. 

Diagnosis. — The ordinary forms of erythema are distinguished from 
erysipelas, by the absence of any very decided burning pain, and tumefac- 
tion of the integument, and tendency to spread, and by less marked con- 
stitutional symptoms. In those forms of erythema in which there is infil- 
tration and swelling of the skin and subcutaneous connective tissue, the 



TREATMENT. 703 

patches are distinguished from those of erysipelas by being multiple, of 
smaller size, less hot and painful, not extending, and presenting as they 
disappear the phenomena of a bruise. In urticaria the wheals that come 
and go suddenly with a peculiar stinging sensation, and the irritability of 
the skin by which these wheals can be produced by slight friction, differ 
in so marked a degi-ee from the symptoms and appearances of erythema 
that the differential diagnosis of the two is easy. In roseola the eruption 
ordinarily occurs over a large part, if not the entire surface, in points and 
small patches with healthy skin between, and presenting a rosy instead of a 
bright-red color, characters which sufficiently distinguish it from erythema. 
Erythema when extensive is sometimes mistaken for the scarlatinous 
eruption, but the redness of the fauces, graver constitutional symptoms, 
vomiting, persistence of the eruption, etc., serve to distinguish the latter 
from the former affection. In cases of doubt it is proper to defer the diag- 
nosis for a day or two, when if the rash is erythematous it will fade. Ery- 
thema sometimes occurs in the initial stage of variola, when, on account of 
the grave general symptoms it may be mistaken for scarlatina. I have 
more than once known this mistake to be made in the hurried visit of the 
physician. A more careful examination would prevent this error. There 
is little danger of confounding erythema with measles, or the various papu- 
lar, vesicular, or pustular skin diseases. 

Treatment. — Erythema fugax requires no special treatment, unless 
occasional dusting the surface with lycopodium or powdered starch. Those 
forms of erythema which are due to mechanical or chemical irritants soon 
disappear when the cause is removed. In erythema around the anus, pro- 
duced by the irritation of the urinary and alvine evacuations, the diaper 
should be changed as soon as soiled, and if the stools are frequent and acid, 
the alkaline treatment proper for the diarrhoea is useful also for the ery- 
thema. In inflammation from this cause as well as in erythema intertrigo, 
the following prescriptions will be found beneficial : 

R. Piilv. zinci oxid., 

Lycopodii, lia. equal parts. Misce. 
To be frequently dusted upon inflamed surface. 

R. Zinei oxid., ^ij. 
Glycerinie, ^ij. 
Liq. plumb, subacetatis, ^iss. 
Aqua3 calcis, ^vj to viij. Misce. 

In obstinate cases a weak solution of nitrate of silver, sulphate of cop- 
per, or, better, as it docs not stain the linen, sul[)liate of zinc, will frequently 
be followed by immediate improvement. 

II. Zinci M,l|,l, lit., gr. vj. 
Glycerina., .5ij. 
Aq. rnste,^^iv. Misce. 
To be constantly applied between the folds of the skin on linen. 



f04 



ROSEOLA. 



Chlorate of potash, inteniully, to correct the acidity of tlie transpiration 
from the skin in protracted and obstinate cases, and in certain instances 
cod-liver oil and the syrup of iodide of iron, are. called for. If the derange- 
ment of the system, upon which the erythema depends, appears to be of a 
rheumatic character, colchicum or alkalies may be required. Erythema 
papulatum, tuberculatum, and nodosum occur most frequently in reduced 
states of the system, and therefore require tonics. 

Roseola. 

The term roseola is applied to rose-colored spots or patches of greater or 
less extent, accompanied by a degree of febrile reaction, and often by red- 
ness, with little or no swelling of the faucial surface. It is attended by a 
sensation of warmth and slight itching. The following groups and sub- 
divisions embrace the recognized varieties of this disease : 



Roseola. 
Idiopathic. Symptomatic. 

Infantilis. Variolosa. 

^Estiva. Vaccinia. 

Auturanalis. Miliaris. 

Annulata. , Rheumatica. 

Punctata. Arthritica. 

Cholerica. 

Febris continual. 

Syphilitica. 

The color of the eruption gradually fades from a rose-red to a duller 
hue, and often disappears in two or three days. In other instances the 
eruption lasts a week or more. Roseola may occur in any season, but it 
is most common, especially the idiopathic form, in the warm months. 
Those varieties of the idiopathic disease which are designated infantilis, 
iBstiva, and autumnalis are the most common in early life. They are in 
reality identical, or nearly so, and may be described as one disease. 

Symptoms. — Roseola infantilis, sestiva, or autumnalis may be partial, 
appearing upon the arras and legs, or general. It is often preceded by 
febrile movement, languor, and in those old enough to describe their sen- 
sations, pain in head, back, and limbs. There is great difference, however, 
in different cases as regards the severity of the prodromic symptoms. They 
may be absent or so slight as scarcely to be appreciable. Occasionally 
vomiting, diarrhoea, or other symptoms of dei'augement of the digestive 
apparatus immediately precede the eruption. 

The eruption of roseola, when general, usually commences upon or about 
the neck and face, and in the course of twenty-four to thirty-six hours 
appears upon the rest of the surface. It bears considerable resemblance 



CAUSES — PROGNOSIS DIAGNOSIS. 705 

to that of measles. The patches are irregular in shape, a quarter to half 
an inch in diameter, and, though of a rose color at first, they soon present 
a dusky hue as they begin to fade ; by pressure the redness disappears. 
In the majority of cases the eruption has nearly faded by the fifth day. 
The redness of the faueial surfiice, together with the itching or tingling, 
disappears with the subsidence of the rash. 

Roseola annulata is a rare disease. It commences with constitutional 
symptoms, which are slight or pretty severe, and which cease when the 
eruption appears. This occurs in the form of red circular spots, which 
enlarge to the diameter of an inch or thereabout and assume the shape of 
rings inclosing healthy skin. The rash fades in a few days, often leaving 
a bruised appearance. The ordinary location of this form of erythema is 
upon the abdomen, and about the thighs. In roseola punctata the eruption 
is of small size, and it occurs upon a large part of the surface. 

Symptomatic roseola, which appears in the course of various diseases, 
need only be alluded to. The diseases in which it is developed are, with 
the exception of syphilis, chiefly of an acute febrile or inflammatory char- 
acter. This eruption is often really, as stated by Tilbury Fox, a rose- 
colored erythema, but in other instances it presents the typical form and 
appearance of roseola. Thus I have known it to occur about the eighth 
or ninth day of vaccinia in rose-colored spots over the whole surface, and 
producing much anxiety on the part of parents, lest impure virus had been 
employed. 

Causes. — These are in a measure obscure. The delicacy of the skin in 
infancy and the active cutaneous circulation no doubt predispose to roseola 
and erythema, and hence the frequency of their occurrence in acute febrile 
and inflammatory afl^ections. Summer weather, with the derangements of 
system which it produces, has been in my experience much the most fre- 
quent cause of idiopathic roseola in young children in this city. In cer- 
tain summers, as in that of 1868, a large proportion of the infants have 
been aflTected by it, and I have been led to consider it a favorable prog- 
nostic sign as regards the diarrhoeal affections, which are so common in the 
warm months. 

Prognosis. — Roseola is always a mild and favorable disease. 

Diagnosis. — Roseola is distinguished from measles, by the absence of 
catarrhal symptoms, a less degree of fever, less uniformity in the size of 
the eruption, and the absence of any history of contagion. Roseola is 
distinguished from erythema by the smaller size of the eruption and its 
rosy or dusky red color. The boundary line, however, between the two 
diseases is not well defined, and certain forms of roseola might be de- 
scribed as erythema. The general but punetiform efflorescence, increase 
of temperature, acceleration of pulse, and the peculiar appearance of the 
tongue and fauces, serve to distinguish scarlet fever from roseola. There 

45 



706 URTICARIA. 

is little danger of confouuding roseola with urticaria, since the wheals of 
the latter appear in no other disease. 

Treatment. — This is simple. If roseola occur in connection with gastro- 
intestinal derangement or disease, the remedies which relieve the latter 
exert a curative effect upon the former. In all cases the state of the system 
should be inquired into, and any departure from a state of health cor- 
rected. Koseola needs no farther constitutional treatment. If there is 
itching or tingling of the surface, a lukewarm lotion, containing equal parts 
of liq. ammon. acetat. and mistura camphorte, has been recommended, or 
a lotion containing a drachm of hydrocyanic acid to a pint of an emulsion 
of bitter almonds, used warm. The purpose of such lotions is simply to 
relieve the unpleasant sensation. Cold applications, or others which would 
repel the eruption, should be avoided ; such an effect might be injurious. 
In cases of acidity of stomach alkaline remedies are useful, and in certain 
cases tonic treatment is indicated. 

Urticaria. 

The name by which this disease is designated is derived from the term 
iirtica, the nettle, the sting of which produces this form of eruption. The 
eruption occurs suddenly in wheals or pomphi, attended by tingling and 
burning, and suddenly disappearing. Urticaria is often accompanied by 
no very decided general symptoms, but in other cases there are febrile 
movement, and lassitude, with perhaps epigastric pain and headache. The 
wheals may occur over the whole body, but more frequently are confined 
to a portion of it. Their shape may be round, oval, irregular, or baud- 
like, and their length varies from a few lines to several inches. In one 
affected by urticaria the wheals can be readily produced by scratching or 
rubbing the surface. The eruption is thus clearly described by a recent 
writer : " At first a bright flush appears, the centre of this becomes slightly 
elevated, and pales, hence appears of lighter color; the tint may be rosy, 
but more generally it is whitish." The margin of the wheal, the diameter 
of which varies, always remains red. This eruption appears to be pro- 
duced by active congestion of the cutaneous capillaries, some serous effu- 
sion, and spasm of the muscular fibres of the skin. The effusion of serum 
in certain localities is quite apparent from the oedema which occurs. The 
subsidence of the eruption is without desquamation. Urticaria is ordi- 
narily an acute disease. It is sometimes chronic in the adult, but rarely so 
in children. Several varieties of it are described by dermatologists, accord- 
ing to the cause, appearance, and duration. 

Causes. — These are external and internal. Various irritants apart 
from the nettle applied to the surface produce the wheals, as the bites of 
certain insects and sometimes turpentine. The following are the principal 
internal causes, as summarized by Hillier : 1st, profound and sudden men- 



PAPULAE DISEASES. 707 

tal emotion ; 2d, certain articles of diet, as shell-fish, pork, sausage, cheese, 
etc.; 3d, certain medicinal substances, as copaiba, valerian, and turpen- 
tine ; 4th, intestinal worms, though it is probable that these seldom operate 
as a cause ; 5th, uterine ailments, as hysteria. 

Peogkosis — Diagnosis. — The prognosis is good, though the chronic 
form is sometimes tedious and troublesome. The occurrence of the wheals 
and the possibility of producing them by friction serve to distinguish this 
disease from all others. 

Treatment. — In urticaria due to any recent ingesta of an irritating or 
indigestible character, an emetic of ipecacuanha is useful, followed by a 
saline, and better also alkaline aperient, as Rochelle salts. An aperient 
of this character is useful ordinarily in acute cases, attended by febrile re- 
action. The diet for several days should be simple, and such as is readily 
digested, as fresh beef, bread, or other farinaceous food, and milk. Occa- 
sionally the wheals appear periodically, when a few doses of quinine effect 
a prompt cure. After the above measures have been employed, the sub- 
sequent treatment, whether tonic or otherwise, depends on the condition of 
the patient. Little benefit accrues from local measures. Sponging the 
surface with cool water to which a little vinegar is added relieves, in a 
measure, the heat and tingling of the wheals. 



CHAPTER 11. 

PAPULAE DISEASES. 
STROPHULUS. 

The three papulse, namely, lichen, prurigo, and strophulus, which are 
characterized by small and firm elevations upon the skin, occur in chil- 
dren ; but the two former are not common, and, as they do not differ in any 
essential particular from the same diseases in the adult, they will not be 
treated of in this connection. Strophulus, on the other hand, is a disease 
peculiar to children. It is known as the red gum or white gum according 
to its appearance, and also as the tooth rash. This eruption appears 
usually on parts which are exposed, as the face, neck, and extremities ; 
the papules being in some patients of tliesize, or even smaller, than a pin's 
head, while in other cases they are as large as a millet-seed. 

The varieties of strophulus described by dermatologists are: 

S. intertinctus. S. candidus. 

" confertus. " volaticus. 

" albidus. " pruriginosus. 



708 PAPULAR DISEASES. 

The following are the characters of these varieties : S. iutertinctus, 
papules a bright red, and occurring chiefly upon the cheeks, forearm, and 
back of hand ; often intertuidured with blushes of erythema; it lasts from 
two to four weeks, and is most common in young infants. S. confertus, 
papules numerous, and closely aggregated, paler, continuing longer than 
in strophulus iutertinctus, and likely to recur, appearing about the time of 
dentition, and most frequently upon the arm. Sometimes certain of the 
patches become chronic, slowly disappearing, and leaving the skin rough 
and dry. S. volaticus appears usually upon the arms and cheeks in patches 
of about a dozen, fewer or more, papules, which soon disappear. These 
patches reappear at intervals for two or three weeks, and are attended by 
heat and itching, though not intense, S. albidus, so called, should really 
be placed among the diseases of the sebaceous glands, and described under 
another name. It appears in the form of small white elevations as large 
as a pin's head, commonly upon the face and neck, and produced by dis- 
tension of the sebaceous glands with the secreted product. The terra 
strophulus candidus is applied to large whitish papules, which appear upon 
the sides of the trunk, shoulders, and arms of infants of one year or there- 
abouts, and disappear in about one week. They are apt to be associated 
with the papules of strophulus confertus. S. prurigiuosus is really a form 
of lichen, occurring chiefly over the age of one, and under that of eight or 
nine years. The papules, which are small and discrete, usually appear 
over a large extent of surface, ordinarily upon the back, fi*ont of the chest, 
the face and arms, and, as they are scratched from the itching, minute 
dark points of blood collect and dry upon their apices. This form of 
strophulus is more protracted than the others, and, in consequence of the 
irritation produced by the scratching, pustules of ecthyma often occur 
among the papules. The apparent cause of strophulus prurigiuosus is a 
mode of life which impoverishes and vitiates the blood, such as uncleanli- 
ness, residence in damp, dark, overheated, and overcrowded apartments. 
Atmospheric heat also operates as a cause, and it is a not infrequent dis- 
ease in the cities during the summer months. 

The various eruptions included under the term strophulus have such 
diflerent anatomical characters, that a proper classification would locate 
some of them in other groups of skin diseases. One form of it, as we have 
seen, is produced by distension of the sebaceous glands ; in other and the 
majority of cases, as appears from the recent observations of Mr. Fox, its 
seat is the sweat glands, and in others still the papillary layer of the skin, 
as in lichen, the papules being produced by an exudation. 

Treatment. — Personal cleanliness, with frequent change of linen, and 
daily ablution without the use of soap, should be enjoined. Local irritants, 
which might aggravate or cause the disease, should, so far as practicable, 
be removed. Alkalies in cases of acidity of the primce vice, and occasion- 
ally mild aperients, are required ; the food should be bland, but nutritious, 



ECZEMA. 709 

and if the child is nursing, it may be necessary to attend to the health of 
the wet-nurse. Favorable hygienic conditions important for the successful 
treatment of all forms of strophulus are especially required in strophulus 
pruriginosus. Nutritious diet, fresh air, quinine, iron, cod-liver oil, etc., 
should be prescribed for those affected by it. The following formula is 
recommended for sponging the surface in cases of strophulus : 

R. Soda3 carbonat., 9J. 
GlycerinEe, ^ij. 
Aq. rosse, ^vj. Misce. 



CHAPTER III. 

ECZEMA. 

This is one of the most common maladies of the skin. It constituted 
one-third of Devergie's cases, and one-sixth of Hillier's. In the commence- 
ment of the eczematous eruption the skin presents a superficial redness, and 
upon this inflamed area numerous minute and closely aggregated papules, 
vesicles, or, more rarely, pustules, soon appear. These are very fragile, so 
that they soon rupture, the epidei'mis is broken and destroyed, and the sur- 
face is moistened by an effusion which appears to be serum, and cannot be 
distinguished from it by the microscope. This liquid when dry stiffens 
linen. As it dries thin crusts form, of a light-yellow color, in most locali- 
ties, but thicker, and of a deeper yellow color upon the scalp. The crusts 
consist mainly of pus, epithelial cells, and granular matter. 

Anatomy. — Biesiadecki has described the formation of the eczematous 
eruption. According to him the papules are produced from the papillae, 
which increase in size by cell formation in their interior. The connective- 
tissue corpuscles enlarge, and are unusually " rich in fluid," and their num- 
ber increases. Under the microscope spindle-shaped corpuscles are ob- 
served, filling the papillae, and extending up from them into the rete Mal- 
pighii, crowding apart the cells of this layer, and reaching and elevating 
the epidermis. The epithelial cells in the immediate vicinity of the 
papillae also become swollen. This cell-growth produces the eczematous 
papule. 

If the cell formation continues within a papilla, certain of the cells are 
ruptured, and as they are very moist a liquid is effused, which raises the 
epidermis over the summit of the papilla. This produces the eczematous 
vesicle. Occasionally pus mixes with this liquid, and the eruption is then 
vesico-pustular. 



710 ECZEMA. 

In acute eczema the upper part of the true skin is infiltrated and swollen, 
while the lower part is commonly unaffected, except in the most severe 
cases. The older the eczema the greater the extent of the infiltration, so 
that in chronic eczema the whole thickness of the skin is more apt to be 
involved than in acute forms of the malady. The discharge of the eczema- 
tous surface is irritating, and healthy skin, with which it may come in con- 
tact, is often reddened by it and made eczematous, from its irritating effect. 
This eczema occurring upon a part of the surface which is in contact with 
an opposite surface of sound skin, commonly affects the latter, and as Neu- 
mann has stated, a nurse, by carrying an infant having eczema upon its 
nates, may contract the same disease upon her arm, although there is no 
contagious principle in this malady. 

Etiology. — Eczema is often produced by irritating substances applied 
to the skin. Croton oil, certain soaps, the finger nails in scratching, a hat, 
truss, or belt, by pressure may produce it. Those having a tender and deli- 
cate skin are more liable to it than others. The constitutional causes are 
often obscure. It is sometimes obviously due to indigestion, or a diet which 
disagrees, for we see it occur in nursing infants as a result of sickness of the 
mother. Ansemia and scrofula are occasional causes. Among the city poor 
eczema is common, and many of the children who have it are scrofulous, 
but a large proportion show no evidence of struma, and in the better classes 
of society a majority do not. 

Varieties — Symptoms — Course. — Eczema is sometimes designated 
according to its location as E. faciei, capitis, etc. Another designation, 
which has more scientific value, is according to the form and stage of the 
eruption, by which we have the following recognized varieties, to wit : 
Eczema papulosum, vesiculosum, pustulosum, rubrum, impetiginosum, and 
squamosum. A simpler and still more convenient classification is into 
eczema simplex, rubrum, impetiginosum, and squamosum. 

Eczema of the scalp is common in infancy, occurring as an eczema rubrum 
or impetiginosum. The eczematous exudation mingling with the secretion 
of the sebaceous glands, which are numerous upon the scalp, forms a thick 
yellow crust. It is apt to extend beyond the hairy portion to the forehead 
and around the ears. This extension aids in establishing the diagnosis 
between eczema and certain other cutaneous eruptions of the scalp. Eczema 
of the external ear is sometimes primary, but in other instances it is con- 
secutive to that of the scalp, and due to the extension of the latter. Its 
common seat is in the angle behind the ear, and upon the lobe of the ear, 
whence it often extends along the auditory meatus, narrowing its calibre, 
and> impairing the hearing temporarily, or even for yeai-s. Eczema upon 
the forehead commonly occurs in children from extension of the eruption 
from the scalp. The cheeks, lips, and chin are often also affected by ec- 
zema, which in this situation is commonly eczema rubrum, and is attended 
by redness, swelling, and troublesome itching. The swollen and red ap- 



DIAGNOSIS. 711 

pearance with the crusts and marks produced by scratching often greatly 
disfigure the countenance. In children, when eczema occurs upon other 
parts, it is usually associated with that of the scalp, face, or ears — that in 
the latter situations being the most severe and obstinate. 

Eczema simplex is common in the summer months, being produced by 
the heat of the atmosphere, aided perhaps by other causes. The patient 
may appear well, or be somewhat indisposed, having febrile symptoms, and 
soon an erythematous patch of greater or less extent appears, upon which 
a cluster of the characteristic papules or vesicles soon occurs. These break, 
forming slight crusts, which are detached, and the eczema declines, or it 
may continue longer, with successive crops of the eruption. 

In eczema ruhrum, since it is a more severe form of the disease, the febrile 
movement and the local symptoms are greater than in the preceding va- 
riety, and the eczematous patch presents the appearance of a more intense 
inflammation. The papules or vesicles are often so minute as to be with 
difficulty recognized. They are soon broken, when they form with the se- 
cretion and exudation from the surface yellowish or brownish-yellow scabs. 
The discharge is more irritating as it is more abundant than in eczema 
simplex, and the adjacent skin is usually more inflamed from its contact. 

Eczema impetigwodes is common in young debilitated children, in whom, 
in consequence of the cachexia, inflammations, of whatever character, are 
apt to be suppurative. This form of eczema presents at first the symptoms 
and features of eczema rubrum, but the transparent liquid of the vesicles 
soon becomes opaque, from the generation and admixture of pus-corpuscles. 
The crusts, which form from the rupture and desiccation of the vesiculo- 
pustular eruptions, are thick and greenish-yellow, and in infants the seba- 
ceous glands, which are involved in the inflammation, pour out an abundant 
secretion, increasing the thickness of the crusts. This form of eczema is 
most common in infancy, and its usual seat is upon the scalp. 

Diagnosis. — Eczema presents in different instances so different an ap- 
pearance that it is not always readily diagnosticated. It will aid in its 
diagnosis to recollect that it is in its nature a moist eruption, affecting 
primarily and chiefly the upper portion of the derma and the Malpighian 
layer, and although it may, at present, present a dry or scaly appearance 
(E. squamosum) yet its history will show that there has been a discharge 
or moisture. In a large proportion of cases, the physician is not able to 
detect papules or vesicles, since they are fragile and transient, breaking in 
the first thirty-six hours, and not reappearing. Still, when they are absent, 
we sometimes observe around the margin of the patch an appearance which 
indicates that they have been there. Their minuteness is occasionally such 
that they may escape notice, on a cursory inspection, when they are present 
and well defined. Acute eczema, affecting a considerable extent of surface, 
is often attended by febrile movement, and might be mistaken for one of 
the eruptive fevers, but the absence of certain distinctive appearances, 



712 SCABIES. 

which characterize these fevers, and the speedy appearance of the eruption 
and moisture, establish the diagnosis. Eczema can be readily diagnosti- 
cated from ordinary erythema, which is a superficial inflammation without 
moisture. The location of erythema intertrigo serves for its diagnosis, as 
it is evidently produced by the attrition of opposite surfaces of the skin. 
Moreover it lacks the vesicular eruption, and the discharge does not stiffen 
linen like that of eczema. Lichen, wheji acute, presents some resemblance 
to eczema, but it is dry and papular, the papules though small, being de- 
tected by the finger as well as sight. The large and irregular phlycta^na, 
intense inflammation, and oedema, and mode of extension of erysipelas, 
large, scattered, and non-inflammatory vesicles of sudamiua, scattered and 
acuminate vesicles, without surrounding inflammation of scabies, are so 
different from the eczematous eruption that the differential diagnosis is 
readily made. Herpes circinatus can be distinguished from eczema by its 
circular shape, larger size, and greater permanence of the vesicles, and the 
delicate, branny scales, which consist rather of epithelial cells than the 
product of exudation as in eczema. 

Treatment. — If the symptoms and history indicate some fault of sys- 
tem, to which .the eczema is probably due, measures calculated to remove 
this cause should obviously be employed. In the cities strumous cases are 
common, and such require the use of cod-liver oil and the syrup of the 
iodide of iron. But in many cases there is no apparent fault of system, 
though there can be little doubt that there is some constitutional cause of 
the eruption. Wilson and some other dermatologists rely greatly on in- 
ternal treatment by arsenic and iron, but in the large number of cases that 
apply to the Outdoor Department of Bellevue, and in cases treated else- 
where, I have not observed such benefit from arsenic as to justify me in 
recommending it. In fact a large proportion of cases appear to be amen- 
able to strictly local measures. I have found no treatment so satisfactory 
as the following : The eczematous patch is bathed several times daily with 
a solution of borax, two or three heaped teaspoonfuls to a pint of water, 
and when the surface has dried, the following ointment is thoroughly ap- 
plied : 

R. Ung. Zinci Oxid., ^ij. 

Ung. Acid. Carbolic, _5J. 

Ung. Hj'drarg. Nitratis., ^iij. Misce. 

This ointment is too irritating for erythema intertrigo which often ac- 
companies eczema. For this the simple zinc ointment is preferable. 

Scabies. 

The diseases of the skin previously considered are non-contagious. 
Scabies, on the other hand, is one of the most contagious diseases by contact. 
It is produced by an animal parasite, known as the itch-mite, or acariis 



SCABIES. 



713 



scabiei. The inflammation is caused by the female only, which burrows, 
making for itself a canal, or cuniculus, in which its eggs are deposited. 
The male does not burrow, but conceals itself under the scales or crusts 
which result from the inflammation produced by its partner, or it burrows 
only sufficiently to produce a covering and shelter. From observations 
made by Eichstedt, Gudden, and others, the female has been found within 






Fig. 21. The itch animalcule, acarus scabiei, viewed upon the back, showing its figure and the 
arrangement of its spines and filaments. The female, which is somewhat larger than the male, has 
a length of l-80th to l-60th of an inch. 

Fig. 22. The foot and last joints of the leg of the itch animalcule. 

Fig. 23. The male itch animalcule, viewed upon the under surface, showing its legs and lobulated 
feet. 

Fig. 24. Ova of the itch animalcule. 

half an hour after being placed upon the skin to have concealed herself 
in the epidermis, and the cuniculus which she constructs is arched and 
tortuous, and four or five lines in length, shorter or longer. The acarus 
has the shape of a tortoise. It can when fully grown be detected by the 
eye as a minute whitish point. The young acarus has six, the mature 
eight, articulated legs, with suckers upon the two anterior pairs, and hairs 
on the posterior. The head, which can be elongated or retracted, is pro- 
vided with two jaws. The upper surface is covered with spines directed 
backwards so as to prevent retrogression in the burrow. She leaves be- 
hind her in the cuniculus, as she advances, her moulted skin, excreta, and 
eggs, which hatch on the eleventh day. The mother acarus is always 
found at the remote end of the burrow, where it can be seen by the un- 
assisted eye as a minute whitish or sometimes brownish speck, and from 
which it can be lifted by the point of a needle to which it clings. The 
cuniculi can also be seen by the naked eye, looking, says Niemeyer, like 
the " scars of needle scratches," and containing the young acari in various 
stages of growth. 

The acarus by its burrowing produces an irritation and troublesome 



714 SCABIES. 

itcliiiig, which is the cliief cause of the suffering of the patient. At the 
point where the acarus penetrates the cuticle the inflammation gives rise 
to a single, small, and acuminate vesicular or papular eruption, the cu- 
niculus extending away from it. We often find ecthymatous pustules and 
abrasions intermingled with the vesicles, the result of the frequent scratch- 
ing. The itching is most intense, and the acarus most active, at night, 
when the patient is warm in bed. Scabies most frequently appears, es- 
pecially in adults, first upon the hands, between the fingers, where the skin 
is thin, and it extends thence along the forearm, and over the thighs and 
abdomen. In children it not infrequently occurs upon the buttocks, thighs, 
feet, etc., while the hands and forearm escape. 

Diagnosis. — Correct diagnosis is important, because the treatment re- 
quired is different from that in any other exanthem, and because the sus- 
picion of having this disease always renders one solicitous to know the 
exact nature of the eruption. Scabies can be diagnosticated from those 
diseases for which it might be mistaken by the following characters : its 
occurrence where the cuticle is thin and delicate, as between the fingers, 
along the anterior aspect of the forearm, upon the abdomen, thighs, and 
inside of the feet; small size, acuminate shape, and isolated position of 
vesicles : the intermingling with the vesicles of other forms of eruption, 
as papules and pustules, and the presence of linear scars and abrasions 
produced by the scratching ; itching most intense at night ; absence of fever ; 
absence of the disease from posterior aspect of body and arms, and from 
head and face. Scabies may be distinguished by the vesicular character 
of the eruption from all other exanthematic affections except eczema, 
sudamina, and herpes. Eczema is most common on the scalp and face, 
where scabies does not occur, and unlike scabies its vesicles are round and 
thickly aggregated in clusters ; in eczema there is a smarting or prickling 
sensation very different from the intense itching of scabies. In herpes 
the vesicles are large, rounded, and in clusters, and attended by a burning 
or pricking sensation, with but little itching. The eruption in sudamina 
is vesicular and discrete, as in scabies, but it is globular, and accompa- 
nied by no itching or other local symptoms. 

Treatment. — As scabies is due to a species of acarus which burrows 
in the epidermis, it can only be treated successfully by measures which 
destroy this animalcule. If it is destroyed, the disease gets well of itself. 
Sulphur has been employed for a long period for this purpose, since sul- 
phurous acid, which is evolved from the sulphur, is destructive to the ani- 
malcule. The unguentum .sulphuris, if thoroughly applied, will rarely 
fail to eradicate the disease. The internal use of sulphur aids the ex- 
ternal treatment, since a portion of the gas which is generated escapes 
through the pores of the skin. The chief objection to the employment of 
sulphur is its exceedingly unpleasant odor, which is noticeable, however 
disguised by perfume. Sulphur or any other substance employed exter- 



TREATMENT. 715 

nally has more effect if it is preceded by a bath, which softens the epider- 
mis, and therefore favors the entrance of the remedy into the pores of the 
skin and the cuniculi. 

Helmerich's ointment is very effectual in the treatment of scabies. It 
consists of two parts of sulphur, one of carbonate of potash, and eight of 
lard. "M. Hardy afterwards perfected the method, so as radically to 
cure the disease in two hours. He proceeds in the following manner : 
The patient first undergoes a friction of his whole body for half an hour 
with soft soap, in order to cleanse the skin and break up the burrows ; a 
warm bath of an hour's duration follows, during which the skin is thor- 
oughly rubbed, in order to complete the destruction of the burrows ; after 
which frictions for half an hour and upon the whole surface are practiced 
with Helmerich's ointment. This completes the cure. Out of four hun- 
dred patients subjected to this treatment, only four returned to the hos- 
pital." (Stille's Therapeutics, etc., vol. ii, page 516.) 

M. Albin Gras experimented with different substances, in order to ascer- 
tain their relative destructiveness to the acarus. The following table 
gives some of the results of his exijerimeuts : 

Immersed in pure water the acarus was alive after three hours. 

" saline water the acarus moved freely after three hours. 

" Goulard's solution the acarus lived after one hour. 

" olive, almond, or castor oil the acarus lived more than two hours. 

" lime-water the acarus died in three-fourths of an hour. 

" vinegar " " twenty minutes. 

" alcohol " " " " 

" turpentine " " nine " 

" iodide of potassium the acarus died in four to six minutes. 

It is seen that vinegar, lime-water, alcohol, turpentine, and iodide of 
potassium destroy the acarus in a short time. They may be employed in 
the same manner as the sulphur ointment. Camphor is also destructive 
to this animalcule, and the linimentum camphorse, thoroughly applied, is 
a good remedy for uncomplicated scabies. 

In order to avoid the odor of sulphur, which is so offensive, one of the 
following ointments may be employed, if the patient is fastidious : 

R. Unguent, hydrarg. ammoniat., 5J. 
Moschi, gr. ij. 
01. lavcnduL, gtt. ij. 
01. amygdal., 3J. Misce. (From Wilson.) 

This should not be used if the scabies is extensive, but the following, 
which is recommended by Bazin, and is said to cure the disease with three 
applications : 

B;. Antliemis pulv., 
Adipis, 
01. olivn3, aa 5J. ]\risce. 



716 SCABIES, 

In cases Avhich have been protracted, and in which ecthymatous and 
other secondary eruptions have occurred, the scabies can ordinarily be 
readily cured, while the other eruptions remain and disappear more 
slowly. A knowledge of this is important, since the sulphur, or other 
ointment employed for the cure of scabies, should be discontinued when 
the itching ceases and vesicles no longer appear, and tonic, or other treat- 
ment appropriate to cure these secondary eruptions, should be employed 
instead. The sulphur ointment continued, after the scabies is cured, does 
harm, as it irritates the cuticle. It is essential in the treatment of scabies 
that the linen be frequently changed. 



INDEX. 



Abdomen, its appearance in disease, 82 
Abdominal organs in tuberculosis, 122 
Abscess, peri-pharyngeal, 681 

age, causes, 582 

anatomical characters, 583 

symptoms, 583 

diagnosis, 586 

prognosis, 587 

treatment, 587 
Accidents incidental to lirth, 59 
Acephalus, 323 

anatomical characters. 324 

symptoms, 324 

prognosis, 324 
Acid, hydrocyanic, in pertussis, 255 
Ackerman, Dr., case of thoracentesis, 549 
Acne syphilitica, 141 

AUin, Dr., statistics of peri-pharyngeal ab- 
scess, 581 
Anencephalus, 323 
Animal heat, 80 
Anstie, Dr., when thoracentesis is required, 

547 
Apnoca neonatorum, 59 

its treatment, 60 
Armor, Dr.. case of taenia, 648 
Apoplexy, 342 

Aqueous cancer of infants, 663 
Arteritis, umbilical, 66 
Artificial feeding of infants, 27-52 
Asphyxia neonatorum, 69 

its treatment, 60 
Atelectasis, 509 

symptoms, 511 

anatomical characters, 511 

treatment, 512 
Atomizer, its use in croup and diphtheria, 490 
Atrophy of brain, 326 
Attitude in disease, 74 



Barker, Prof. Fordyce, on turpeth mineral in 

croup, 488 
Baths, 58 

Belladonna for hooping-cough, 253 
Billard, on softening of stomach, 600 
Blue disense, 683 
Bouchut. on the effects of the emotions on 

the .secretion of milk, 38 
Bowditch, Dr., on thoracentesis, 545 
Brain, its chemical analy.sis, 323 

its growth, 323 
Brain, atrophy of, 327 
Brain, conge.'^tion of, 337 



Brain, hypertrophy, 328 

pathological anatomy, 328 

causes, 329 

symptoms, 330 

diagnosis. 331 

prognosis, treatment, 332 
Brain, imperfect, 325 

case, 326 

symptoms, prognosis, 326 
Brain in tuberculosis, 124 

symptoms of cerebral and meningeal 
tubercles, 126 
Brice's test, 209 

Brodie, Sir Benjamin, on mercurial inunc- 
tion, 145 
Bromides for pertussis, 256 
Bronchitis, 497 

causes, anatomical characters, 497 

symptoms, 501 

capillary bronchitis, 502 

chronic bronchitis, 603 

diagnosis, prognosis, 504 

treatment, 505 
Bronchial phthisis, 121 

its symptoms, 128 
Brown-Sequard, Dr., on compression of sym- 
pathetic nerve for eclampsia, 393 
Bruit de soufflet at anterior fontanelle, 93 
Biichler, Dr., cases of intussusception, 628 
Budd. Dr. William, on prevention of scarlet 

fever, 184 
Bulbous fingers, 73 
Bulkley, Dr. L. D., on dactylitis syphilitica, 

143 
Byrd, Prof., on resuscitation of the newborn, 
"60 



Camraann, Dr., treatment of nervous cough, 

551 
Cnncrum oris, 563 
Caput succedaneura, 61 
Caro, Dr.. treatment of croup, 492 
Cnstor oil as a galactogogue, 45 
C'atnmenia, its effect upon the milk, 38 
Cavities in lungs, 120 
Cephalsematoma, 67 
Cerebral hsemorrhnge, 345 
Cerebro-spinal fever, 276 

its cause, 276 

sex, age, 280 

symptoms, 281 

cases, 281 

mode of commencement, 282 



718 



Cerebro-spinal fever, symptoms pertaining to 
nerv(iu.« sysftem, 2S.'J 

digestive system, pulse, 286 

temperature, 287 

respiratory system. 289 

cutaneous surface, 289 

nature, 293 

prognosis, 295 

diagnosis, 297 

anatomical characters, 297 

treatment, preventive, 301 
curative, 302 
Cerebro-spinal system, its diseases, 322 
Cheesy substance a cause of tuberculosis, 115 
Chicken-pox, 212 
Childhood, 19 
Cholera infantum, 637 

causes, 638 

symptoms, 639 

anatomical characters, 640 

nature, 642 

diagnosis, prognosis, treatment, 643 
Choleriform diarrhoea, 637 
Chorea (chorea minor), 426 

age, 426 

ciuses, sex, 427 

uterine irritation, 428 

anffimia. rheumatism, 428 

fright, imitation, 431 

cerebral embolism, 430 

intestinal irritation, 432 

lesions of brain and spinal cord, 432 

anatomical characters, 433 

symptoms, 434 

prognosis, course, diagnosis, 436 

treatment, 437 
Chorea major, 431 
Church, Dr. A. S., case of tonic convulsions 

from dentition, 673 
Circulatory system in disease, 77 
Cirrhosis, syphilitic, 142 

Clark, Prof. Alonzo, case of syphilitic com- 
munication, 208 
Clothing. 58 
Colitis of childhood, 634 

causes, 634 

symptoms, 635 

diagnosis, treatment, 636 
Colostrum, 33 

Condie, Dr. D. F., on erysipelas, 317 
Convulsions, internal, 417 

causes, 418 

anatomical characters, 420 

symptoms, 420 

diagnosis, 422 

prognosis, modes of death, treatment, 423 
Congenital hydrocephalus, 352 
Conjunctivitis neonatorum, 62 

its treatment, 65 
Congestion of brain, 337 

causes, 338 

symptoms, anatomical characters, 340 

prognosis, 340 

treatment, 341 
Cord, spinal, its diseases, 456 

congestion, 458 
Coryza, 469 

anatomical characters, symptoms, prog- 
nosis, 470 

treatment, 471 



Cough, nervous, 650 

treatment, 550 
Cranial sinuses, thrombosis of, 333 
Craniotabes, 89 
Cretinism. 329 
Croup, true, 481 
Cyanosi-s, 683 

literature, 684 

sex, causes, 686 

time of commencement, 688 

symptoms. 689 

prognosis, 693 

mode of death, 694 

modes of compensation, morbid anatomy, 
696 

etiology, 697 

treatment, 699 



Dactylitis syphilitica, 143 

Dalton, Prof. J. C, on effe-ts of maternal 

emotions, 22 
Delafield, Dr. Franei.«, ease of croup, 482 
Dentition, 670 

pathological results of, 572 

case, 674 

diagno.-is, 574 

treatment. 675 
Dentition, second. 677 
Dentition in rachitis, 92 
Diagnosis of infantile diseases, 72 
Diarrhoea, 605 

noninflammatory, 605 

causes. 605 

symptoms, 606 

anatomical characters, 607 

diagnosis, prognosis, 608 

treatment, 609 
Diarrhoea, inflammatory. 611 
Diarrhoea, choleriform, 637 
Diet, effects of improper, 26 
Digestion, post-mortem. 600 
Digestive apparatus, its diseases, 552 
Digestive system, 81 
Diphtheria, 215 

age, incubation, 215 

nature, causes, 216 

bacterian theory, 216. 217 

its frequent primary local character, 219 

anatomical characters, 225 

Prof Rindfleisch's views, 228 

symptoms, 232 

sequelae, 236 

paralysis, 236 

prognosis, 237 

diagnosis, 238 

treatment, 240 

local measures. 240 

general measures, 242, 243 

treatment of the paralysis, 244 

preventive measures, 244 

atomizer, its uses in diphtheria, 490 
Diseases of umbilicus, 66 
Donne. M., mode of examining milk, 48 
Dress of infants, 58 
Dropsy of brain, congenital, 352 

acquired, 359 
Ductus arteriosus, 18 
Ductus venosus. 18 
Dysentery in childhood, 634 



INDEX, 



19 



Dyspepsia, 589 

from colostrum, 34 



Eclampsia, 386 

causes, 387 

premonitory stage, 388 

symptoms, 389 

anatomical characters, 391 

diagnosis, 392 

progress, treatment, 393 
Ecthyma, syphilitic, 141 
Eczema, 709 

anatomy, 709 

etiology, varieties, symptoms, course, 710 

diagnosis, 71 1 

treatment, 712 
Elliot, Prof. George T., case of peri-pharyn- 

geal abscess, 683 
Electricity as a means of increasing the milk, 

43 
Emotions, effects of in pregnancy, 20 

on the milk, 38 
Emphysema in pulmonary tuberculosis, ]20 
Entero-colitis, 61 1 
Enteritis of childhood, 634 

causes, 634 

symptoms, 635 

prognosis, diagnosis, treatment, 636 
Erysipelas in mother an objection to lacta- 
tion, 32 
Erysipelas, 312 

age, point of commencement, 314 

causes, 314 

symptoms. 317 
. prognosis. 318 

duration, mode? of death, 319 

pathological anatomy, 319 

treatment, 320 
Erythema, 701 

prognosis, diagnosis, 702 

treatment, 703 
Ether in spasmodic laryngitis, 478 
Evanson and Maunsell, treatment of cancrum 

oris, 569 
Eye, its appearance in disease, 73 



Face, its appearance in disease, 72 

Facial paralysis, 451 

Features in disease, 72 

Feeding, artificial, 27, 52 

Fever and ague, 261 

Fleming, Dr., on retro-pharyngeal abscess, 

583 
Flint, Prof. A., Jr., on diet of children, 26 
Flint, Prof. A.. Sr.. jirevention of pitting in 

sinall-po.\, 201 
Foetus, etfect on it of maternal emotions, 21 
Fracture, rachitic, 92 
Fungus, umbilical, 68 



Gangrene of mouth, 563 

anatomical characters, 563 
age, 564 

causes, symptoms, 565 
diagno^i.", prognosis, 567 
treatment, 568 

Galactorrhoea, 41 



Galaetogogues, 43 

Gas, intestinal, in disease, 81 

Gastritis, 595 

causes, age, 596 

cases, 597 

symptoms, 597 

anatomical characters, diagnosis, 598 

prognosis, treatment, 699 
Gastro-inte.«tinal htemorrhage, 656 
Gastritis, follicular, 699 

diphtheritic, 600 
Gastric softening, 600 

Gee, Dr. Samuel, on state of spleen in hered- 
itary syphilis, 142 
Gelatinous softening, 600 
Glands, treatment of enlarged, 110, 111 
Glottis, spasm of, 417 
Goat's milk, 54 
Granulations, umbilical, 68 
Green, Dr. Caleb, on rotheln, 186 
Grease in the horse, its relation to vaccinia, 

204 
Gummy tumors, 142 



Hcemorrhage, gastro-intestinal, 656 

varieties, 657 

case, 658 

prognosis, treatment, 660 
Haemorrhage from umbilicus, 68 
Haemorrhage, intracranial, 342 

causes, 342 

anatomical characters, 343 

cerebral, 346 

symptoms, 346 

diagnosis, prognosis, 350 

treatment, 351 
Hammond, Prof. William A., effects of ma- 
ternal emotions, 22 
Hassel, Dr., on preparation of Liebig's food, 

56 
Hawley, James S., on Liebig's food, 57 
Head, its appearance in disease, 72 
Heat, animal, 80 
Heitzmann, Dr., investigations relating to 

the diphtheritic pseudo-membrane, 221 
Hewitt, Graily, 588 

Hillier, Dr., on choreic heart murmurs, 426 
Hooping-cough, 246 

symptoms, 246 

periods, first, 247 
second, 247 
third. 248 

complications, 248 

convuli^ions, 249 

bronchitis and pneumonia, 260 

emphysema, 251 

diagnosis, 251 

prognosis, 252 

treatment, 253 
Hutchinson, Mr. J., on development of the 
teeth, 144 

case of laparotomy, 082 
Hughes. Dr., on chorea, 433 
Hydrocyanic acid for hooping-cough, 255 
Hydrocephalus, congenital, 352 

anatomical characters, 352 

symptoms, 356 

diagno.sis, prognosis, treatment, 358 
Hydrocephalus, acquired, 359 



720 



INDEX. 



Hydrocephalus, acquired, causes, 359 

anatomical characters, syuiptoins, 360 

prognosis, treatment, 361 
Ilydrocephalus. spurious, 380 

anatomical characters, 381 

symptoms, 382 

cases, 381-384 

diagnosis, prognosis, treatment, 385 
Hypertrophy of brain, 328 



Icterus of the newborn, 72 
Impetisjo, syphilitic, 141 
Imperfect brain, 325 
Indigestion, 589 

causes, 589 

symptoms, 691 

prognosis, 592 

treatment, 692 

acute indigestion, 592 

chronic. 593 

use of pepsin, 694 
Indigestion from colostrum, 34 
Infancy, 17 

Infantile diseases, their diagnosis, 72 
Infantile mortality, its causes, 23 
Infectious diseases, a cause of the great mor- 
tality of children, 24 
Inflammation, intestinal, 611 

causes, 612 

atmospheric, 613 
dietetic;, 614 

dentition, 615 

age, 616 

symptoms, 617 

anatomical characters, 620 

diagnosis, 625 

prognosis, treatment, 626 

dietetic, 627 

medicinal, 629 
Inflatioi! in treatment of intussusception, 679 
Intermittent fever in pregnancy, 20 
Intermittent fever, 261 

incubation, 262 

symptoms, 263 

treatment. 265 
Internal convulsions, 417 
Intestinal worms, 645 

ascaris lumbricoides, 645 
vermicularis, 645 

tricocephiilus dispar, 645 

taenia, 646-647 
Intestines, inflammation of, 611 
Intestines, the seat of tubercle, 123 
Intussusception, 661 

without symptoms, 662 

with symptoms, 662 

causes, 663 

age, seat, pathological anatomy, 664 

iif small inteftines, 666 

cases, 666-667 

in large intestines, 668 

symptoms, 671 

diagnosis, duration, 673 

prognosis, 674 

modes of death, 676 

treatment, 677 

laparotomy, 682 
Invagination, 661 



Jackson, Dr. James, on second dentition, 677 

Jacobi. Dr. A., weight of parotid gland, 65 
statistics of tracheotomy, 486 

Jacobi, Dr. Mary P., on infantile paralysis, 
446 

Jaundice, a cause of haemorrhage, 70 
in the newborn, 72 

Jenkins, Dr. J. Foster, on umbilical haemor- 
rhage, 69 

Jenner, Edward, introduction of vaccination, 
203 

Jenner, Sir William, heart murmurs in 
chorea, 426 

Jesty, Benjamin, the fi st v.iccinator, 203 



Kermes mineral a cause of gastritis, 696 
Kilda, St., tetanus in, 40i) 
Krackowizer, Dr. Ernst, statistics of trache- 
otomy, 493 



Lactation, mode of determining the capability 
for, 28 

hindrances to, 28 

depression of nipple, fi.-sured nipple, 29 

tuberculosis, 30 

syphilis, inflammations, 31 

erysipelas, 32 

facts and rules in reference to, 33 

colostrum, 33 
Lanugo, 17 

Laparotomy for intussusception, 682 
Laryngitis, simple, 4 72 

symptoms, 473 

anatomical characters, treatment, 474 
Laryngitis, spasmodic, 475 

anatomical characters, pathology, 476 

diagnosis, 477 

prognosis, treatment, 478 
Laryngitis, pseudo-membranous, 481 

causes, anatomical characters, 481 

symptoms, 483 

pathological characters 485 

diagnosis, progno.is, 486 

treatment, 487 

tracheotomy in, 493 
Laryngitis, tubercular, 117 
Laryngitis, stridulous, 417 
Leaming, Dr. J. R , case of erysipelas. 315 
Lebert, M., on structure of gummy tumors, 

142 
Liebig's food, 56 

Limbs, their appearance in disease, 72 
Liver in syphilis, 142 

its state in enterocolitis. 622 
Livingston, Dr., case of peri pharyngeal ab- 
scess, 687 
Lungs in tuberculosis, 117 



Malformations, a cause of death, 23 
Maternal emotions, effects upon the foetus, 21 

effects upon the secretion of milk, 37 
Mayer, Dr., observations on the acidity of 

cows' milk, 36 
Measles, 147 

symptoms, 147 

complications, 150 



INDEX. 



721 



complications, by bronchitis and | Otorrhoea, 

broncho-pneumonia, 150 
by entero-colitis, 151 
by croup and diphtheria, 152 
by gangrene, 152 
anatomical characters, 153 
nature, diagnosis, 153 
prognosis, treatment, 154 
Meconium, 18 
Meigs, Dr. J. P., 483 

effects of chenopodium, 654 
Meningeal hemorrhage, 345 
Meningitis, simple and tubercular. 362 
age, anatomical characters, 364 
causes, 368 
diagnosis, 374 
prognosis, 375 
treatment, 377 
Meningitis, spurious, 380 
Microcephalus, 326 
Milk, human, its composition, 35 
its modification from diet, 35 
Milk, its changes in composition by diet, 36 
its modilication from retention in the 

breast, 37 
its modification by age and nervous im- 
pressions, 37 
its modification by the catamenia and 

pregnanc3', 28 
quantity required by the infant, 40 
differences as regards quantity and quali- 
ty of, 40 
scantiness of, 41 
modes of increasing, 43 
examination of, 48 
vibriones in, 49 
composition of, 53 
Minchin's mode of examining milk, 48 
Minot,Dr. Francis, on umbilical haemorrhage, 



Morbilli, 147 
Mollities ossium, 85 
Mortality of early life, 22 
Mother, care of, in pregnancy, 
Movements in disease, 74 
Muguet, 559 
Mumps, 258 



Navel, its inflammation, 66 

Necrosis, infantile. 563 

Nephritis in scarlet fever, 166 

Nervous cough, 550 

Nervous system in disease, 83 

Nipples, depressed or excoriated, a hindrance 

to lactation, 29 
Noma, 563 
Noyes, Prof. H. D. 

moscope, 321 



on the use of the ophthal 



lagitis, anatomical characters, 588 

treatment, 589 
Oidium albicans, 559 
Ogle, Dr., on chorea, 433 
Ophthalmia neonatorum, 62 

its treatment, 05 
Ophthalmoscope in diseases of brain, 321 
Osteo-malacia, 85 
Otitia, scrofulous, 103 



Pain, a symptom of disease, 83 
Papular diseases, 707 

strophulus, 707 

varieties, treatment, 708 
Paracentesis thoracis, 645 
Paralysis, facial, causes, symptoms, 451 

prognosis, treatment, 452 
Paralysis, infantile, 440 

cure, 442 

symptoms, 443 

prognosis, progress, etiology, 445 

anatomical characters, diagnosis, 449 

prognosis, treatment, 449 
Paralysis with pseudo-hypertrophy, 452 

anatomical characters, 454 

causes, 455 

prognosis, treatment, 456 
Paralysis from tubercles in encephalon, 127 
Parker, Dr. E. H., on treatment of cholera 

infantum, 645 
Parker, Prof Willard, on peri-pharyngeal ab- 
scess, 586 
Parotiditis, 258 

nature, 259 

diagnosis, 259 

treatment, 260 
Peacock, Dr., on the growth of the brain, 323 
Peaslee,Prof. E. R., on treatment of croup,491 
Pemphigus, syphilitic, 141 
Pepsin in indigestion, 594 
Peri-pharyngeal abscess, 581 
Peritoneal tuberculosis, 122 
Pertussis, 246 
Pharyngitis, anatomical characters, 578 

causes, symptoms, prognosis, 679 

diagnosis, treatment, 580 
Phlebitis, umbilical, 66 
Phlebitis, 333 
Phthisis, 112 
Pleuritis, 628 

causes, 630 

cases, 532, 633, 540 

anatomical characters, 533 

symptoms, 535 

physical signs, auscultation, 637 

percussion, 638 

inspection, mensuration, 539 

diagnosis, 641 

prognosis, 542 

treatment, 543 

thoracentesis, 545 
Pneumonitis, 513 

causes, 514 

anatomical characters, 616 

croupous, catarrhal, 616, 517 

cheesy, 519 

symptoms, 520 

physical signs, diagnosis, 523 

prognosis, treatment, 525 
Pneumonitis, tubercular, 119 
Post-mortem digestion, 600 
Poore, Dr., on pseudo-bypertrophic paralysis, 

453 
Post, Prof. A., case of peripharyngeal abscess, 

586 
Pregnancy, its effects on the milk, 33 
Pulmonary cavities, 120 
46 



722 



INDEX. 



Pulse in health, 78 

after excitement, 79 

in disease, 79 
Pus, retained, a cause of tubercles, 115 



Rachitis, 85 

age, 85 

causes, 86 

anatomical characters, 87 

stages, 1st, 87 
2d, 88 
3d, 91 

craniotabes, 89 , 

deformities, 89, 90, 91 ' 

rachitic fracture, 92 

symptoms, 93 

complications, 95 

diagnosis, prognosis, treatment, 96 

reconstruction, 91 
Radcliffe, Mr., on treatment of chorea, 439 
Remittent fever, 266 

symptoms, diagnosis, 267 

treatment, 268 
Respiration in health, 76 

in disease, 76 
Respiratory system in disease, 75 
Reynolds, Dr. J. B., case of diphtheria, 237 
Rheumatism, acute, 306 

causes, symptoms, 307 

duration, prognosis, 309 

treatment, 310 
Ricinus communis, a galactogogue, 44 
Rickets, 85 
Ridge's food, 57 

Robin, Prof. Charles, on gummy tumors, 142 
Rokitansky on hypertrophy of the brain, 329 
Roseola, 704 

causes, prognosis, diagnosis, 705 

symptoms, 704 

treatment, 706 
Rotheln, 184 

age, 1S6 

premonitory stage, 186 

symptoms, 186 

tegumentary system, 186 

a. skin, 186 

b. mucous membrane, 187 
pulse, temperature, 188 
respiratory system, 189 
digestive system, 189 
complications, prognosis, 189 
nature, 189 

Routh, effects of variable temperature on mor- 
tality of infants, 26 
Rubeola, 147 



Sayre, Prof. L. A., on a cause of paralysis, 

457 
Salivary glands, weight of, 55 
Scabies, 713 

acarus scabiei. 713 

diagnosis, treatment, 714 

by sulphur, 714 

Helmerich's ointment, 715 

vitality of the acarus, 715 
Scarlet fever, 156 

symptoms, 156 

regular form, 157 



I Scarlet fever, irregular form, 159 
j malignant fever, 161 

complications, 161 

convulsions, 161 

diphtheria, 162 

gangrene, 162 

entero-colitis, 163 

rheumatism, 163 

pericarditis and pleuritis, 164 

sequelae, 165 

nephritis, 166 

otorrhoea, 168 

anatomical characters, 168 

nature, 169 

its contagiousness, 169, 170 

incubation, 170 

diagnosis, 171 

prognosis, 172 

treatment, 173 

by water, 174 
inunction, 175 
of the nephritis, 179 
of the otorrhoea, 181 

prophylaxis, 182 

belladonna as a prophylactic, 182 

prophylactic regulations of the New 
York Health Board. 183 
Scrofula, 97 

causes, 97 

vaccination a supposed cause, 99 

anatomical characters, 100 

glandular hyperplasia, 101 

symptoms, 102 

two types, 102 

its relation to tuberculosis, 106 

prognosis, treatment, 108 
Seguin, on effects of maternal emotions, 22 
Seguin, Dr. E. C, on infantile paralysis, 446 
Sewell, Dr. John tr., cases of cerebro-spinal 

fever. 278 
Skene, Professor, case of taenia, 648 
Skin diseases, 701 
Small-pox, 192 

Smith, Prof. Stephen, on umbilical haemor- 
rhage, 69 
Softening of the stomach. 600 
Spasm of the glottis, 41 7 
Spine, its diseases, 456 
Spina bifida, 460 

diagnosis, prognosis, treatment, 462 
Spinal cord and membranes, 456 
Spinal cord, its congestion, 458 

anatomical characters, 458 

symptoms, treatment, 459 
Sprue, 559 

Stille, Dr. Moreton, on cyanosis, 686 
Stomach affected with tubercles, 123 

congestion of, 695 

inflammation of, 595 

softening of, 600 

case, 602 
Stomatitis, simple, 552 

causes, 552 

symptoms, appearances, treatment, 553 
Stomatitis, ulcerous, 554 

causes, 554 

symptoms, prognosis, treatment, 555 
Stomatitis, follicular, 556 

anatomical characters, 556 
causes, symptoms, 657 



723 



Stomatitis, diagnosis, prognosis, treatment, 

568 
Stools, their character in disease, 82 
Struma, 97 

Sweezey, Dr., case of peri-pharyngeal abscess, 
584 

treatment of vomiting, 633 
Syphilis in pregnancy, 20 
Syphilis, 136 

etiology, 136 

modes of contagion, 137 

clinical history, 137 

syphilis in the foetus, 138 

time of commencement of symptoms, 139 

color of skin, 139 

coryza, 139 

mucous patches, 140 

roseola, 140 

pemphigus, acne, impetigo, ecthyma, 141 

visceral lesions, 141 

dactylitis syphilitica, 143 

osseous lesions, 143 

state of the testh, 144 

prognosis, 144 

treatment, 145 



Taylor, Dr. R. W., on dactylitis syphilitica, 

143 
Teething in rachitis, 92 
Temperature, in health, 80 
Temperature, effects of changes on mortality 

of infants, 26 
Tetanus infantum, 397 

cases, 398, 399 

age, 400 

frequency, 400 

causes, 402 

symptoms, 411 

modes of death, prognosis, 413 

duration, diagnosis, treatment, 414 
Thrombosis in cranial sinuses, 333 

anatomical characters, 333 

causes, 335 

symptoms, 336 

diagnosis, prognosis, treatment, 337 
Thrush, 559 

anatomical characters, 559 

symptoms, causes, diagnosis, 561 

prognosis, treatment, 562 
Thymic asthma, 417 
Trismus, 397 

Trousseau, symptoms of rachitis, 94 
Trunk, its appearance in disease, 72 
Tuberculosis in mother a hindrance to lacta- 
tion, 30 
Tuberculosis, 112 

etiology, llo 

general amitomieal characters, 115 

yellow tubercle, 1 16 

anatomical characiers in infancy and 
childhood, 1 16 

in lungs, 118 

tubercular pneumonia, 118 

cavities in lungs, 120 

bronchial phthisis, 121 

abdominal viscera, 122 

stomach and intestines, 123 

symptoms, 124 

physical signs, 129, 130 



Tuberculosis, lungs, 129 

pleura, 131 

stomach and intestines, 132 

diagnosis, 132, 133 

prognosis, 134 

treatment, 135 

prophylactic, 135 
curative, 136 
Typhoid fever, 268 

causes, 268 

anatomical characters, 269 

symptoms, 270 

complications, 272 

diagnosis, 273 

duration, 273 

prognosis, treatment, 274 



Umbilical fungus, 68 

hsemorrhage, 68 
Umbilical vessels, inflammation of, 66 
Umbilicus, its diseases, 66 

its inflammations, 66 
Urates, 18 
Uric acid, 18 
Urticaria, 706 

causes, 706 

prognosis, diagnosis, treatment, 70'; 



Vaccinia, 202 

its history, 203 

appearances, symptoms, 205 

anomalies, complications, sequels, 206 

erysipelas, 207 

syphilis, 207 

subsequent vaccinations, 208 

spurious vaccination, 209 

its protective power, 210 

revaccination, 210 

selection of virus, 211 
Van Swieten's remedy, 145 
Varicella, 212 

symptoms, 212 

diagnosis, 213 

prognosis, treatment, 214 
Variola, varioloid, 192 

incubative period, 192 

stage of invasion, 192 

stage of eruption, 193 

stage of desiccation, 195 

mode of death, 196 

anatomical characters, 197 

complications, 198 

prognosis, 198 

diagnosis, treatment, 199 

prevention of pitting. 200 
Varioloid, 196 
Vertebral caries, 464 

symptoms, 466 

diagnosis, prognosis, 467 

treatment, 468 
Vibriones in milk, 49 

Villemin, M., on production of tubercles, 1 14 
Virus, its selection for vaccination, 211 
Voice in disease, 74 
Vomiting as a symptom, 81 



Ware, Dr., statistics of croup, 483 



724 



Warren, Dr., 678 

Weaning, 50 

Wet-nurse, selection of, 47 

White softening, 600 

White, Professor J. P., case of cyanosis 

Wilks, Dr., case of syphili.s, 142 

Worms, intestinal, 645 



Worms, kinds, 646 
causes, 648 
symptoms, 650 
diagnosis, progr 



I Yellow tubercle, 116 



is, treatment, 652 



(late lea & blanchard's) 
OF 

MEDICAL AND SUEGIGAL PUELIGATIOMS, 



In asking the attention of the profession to the works advertised in the following- 
pages, the publisher would state that no pains are spared to secure a continuance of 
the confidence earned for the publications of the house by their careful selection and 
accuracy and finish of execution^ 

The printed prices are those at which books can generally be supplied by booksellers 
throughout the United States, who can readily procure for their customers any works 
aot kept in stock. Where access to bookstores is not convenient, books will be sent 
by mail post-paid on receipt of the price, but no risks are assumed either on the 
money or the books, and no publications but my own are supplied. Gentlemen will 
therefore in most cases find it more convenient to deal with the nearest bookseller. 

An Illdstrated Catalogue, of 64 octavo pages, handsomely printed, will be for- 
warded by mail, post-paid, on receipt of ten cents. 

HENRY C. LEA. 

Nos. 706 and 708 Sajtsom St., Philadelphia, November, 1875. 

ADDITIONAL INDUCEMENT FOK SUBSCRIBERS TO 

THE iMERICAK JOURNAL OF THE MEDICAL SCIENCES. 



THREE MEDICAL JOUEIf ALS, containing over 2000 LAEGE PAGES, 

Free of Postage, for SIX DOLLARS Per Annum. 

TERMS FOE 1876: 
The American Journal of the Medical Sciences, and ] Five Dollars per annum, 
The Medical News and Library, both free of postage, j in advance. 

The American Journal of the Medical Sciences, published quar- "] j,. -p. ,, 

terly (llfiO pages per annum), with | *'^ L»ollars 

The Medical News and Library, monthly (384 pp. per annum), and ]■ per annum. 
The Monthly Abstract of Medical Science (592 pages per I • ■> 

annum), ^ ^ i^ J m advance. 

SEPARATE SUBSCRIPTIONS TO 

The American Journal of the Medical Sciences, when not paid for in advance. 

Five Dollars. 
The Medical News and Library, free of postage, in advance, One Dollar. 
The Monthly Abstract of Medical Science, free of postage, in advance, Two 

Dollars and a Half. 

It is manifest th*at only a very wide circulation can enable so vast an amount of 
valuable practical matter to be supplied at a price so unprecedentedly low. The pub- 
lisher, therefore, has much gratification in stating that the very great favor with which 
these periodicals are regarded by the profession promises to render the enterprise a 
permanent one, and it is with especial pleasure that he acknowledges the valuable 
assistance spontaneously rendered by so many of the old subscribers to the "Jour- 
nal," who have kindly made known among their friends the advantages thus olfered, 
and have induced them to subscribe. Kelying upon a continuance of these friendly 
exertions, he hopes to be able to maintain the une.\ampled rates at which these works 

(For "The Odstetuical Journal," see p. 22.) 



2 Henry C. Lea's Publications — (Am. Journ. Med. Sciences). 

are now offered, and to succeed in his endeavor te place upon the table of every 
reading practitioner in the United States the equivalent of three large octavo volumes, 
at the comparatively trifling cost of Six DoLLAKspe?- annum. 

These periodicals are universally known for their high professional standing in their 
several spheres. 

I. 

THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 

Edited by ISAAC HAYS, M.D., 

is published Quarterly, on the first of January, April, July, and October. Each num- 
ber contains nearly three hundred large octavo pages, appropriately illustrated wher- 
ever necessary. It has now been issued regularly for over fifty years, during nearly 
the whole of which time it has been under the control of the present editor. Through- 
out this long period, it has maintained its position in the highest rank of medical 
periodicals both at home and abroad, and has received the cordial support of the en- 
tire profession in this country. Among its Collaborators will be found a large number 
of the most distinguished names of the profession in every section of the United 
States, rendering the department devoted to 

ORIGINAL COMMUNICATIONS 

full of varied and important matter, of great interest to all practitioners. Thus, during 
1874, articles have appeared in its pages from nearly one hundred gentlemen of the 
highest standing in the profession throughout the United States.* 

Following this is the "Eeview Department," containing extended and impartial 
reviews of all important new- works, together with numerous elaborate ''Analytical 
AND Bibliographical Notices" of nearly all the medical publications of the day. 

This is followed by the ''Quarterly Summary of Improvements and Discoveries^ 
IN the Medical Sciences," classified and arranged under different heads, presenting 
a very complete digest of all that is new and interesting to the physician, abroad as 
well as at home. 

Thus, during the year 1875, the "Journal" furnished to its subscribers 98 Orig- 
inal Communications, 95 Reviews and Bibliographical Notices, and 283 articles in 
the Quarterly Summaries, making a total of about Five Hundred articles emanating 
from the best professional minds in America and Europe. 

That the efforts thus made to maintain the high reputation of the "Journal" are 
successful, is shown by tlie position accorded to it in both America and Europe as a 
national exponent of medical progress : — 

America continues to take a great place in this 
class of journals (quarterlies), at the head of which 
the great work of Dr. Hays, the Amtrican Journal 
of the Medical Sciences, still holds its ground, as our 
quotations have often proved. — Dublin Med. Press 
and Circular, Jan. 31, 1S72. 

Of English periodicals the Lancet, and of American 
the Am. Journal of the Medical Sciences, are to be 
regarded as necessities to the reading practitioner. — 
y. r. Medical Gazette, Jan. 7, 1871. 

The American Journal of the Medical Sciences 
yields to none in the amount of original and bor- 

And that it was specifically included in the award of a medal of merit to the Pub- 
lisher in the Vienna Exhibition in 187;]. 

The subscription price of the "American Journal of the Medical Sciences" has 
never been raised during its long career. It is still Five Dollars per annum ; and 
when paid for in advance, the subscriber receives in addition the " Medical News and 
Library," making in all about 1500 large octavo pages per annum, free of postage. 

II. 

THE MEDICAL NEWS AND LIBRARY 

is a monthly periodical of Thirty-two large octavo pages, making 384 pages per 
annum. Its -'News Department" presents the current information of the duy, with 
Clinical Lectures and Hospital Gleanings ; while the " Library Department" is de- 
voted to publishing standard works on the various branches of medical science, paged 



rowed matter it contains, and has established for 
itself a reputation in every country where medicine 
is cultivated as a science. — Brit, and For. Med.-Chi- 
rurg. Review, April, 1S71. 

This, if not the best, is one of the best-conducted 
medical quarterlies in the English language, and the 
present number is not by any means inferior to its 
predecessors. — London Lancet, Aug. 23, 1S73. 

Almost the only one that circulates everywhere, 
all over the Union and in Europe. — London Medical 
Times, Sept. 5, ISbS. 



* Communications are invited from gentlemen in all parts of the country. Elaborate articles iusertcd 
by the Editor are paid for by the Publisher. 



Henry 0. Lea's Publications — (Am. Journ. Med. Sciences). 3 

separately, so that they can be removed and bouad on completion. In this manner 
subscribers have received, without expense, such worlvs as " Watson's Practice," 
"Todd and Bowman's Physiology," "West on Children," '• Malgaigne's Sur- 
gery," &c. &c. W^ith Jan. 1875, was commenced the publication of Dr. AVilliajc 
Stokes's new work on Fever (see p. 14), which will be completed during 1876. 

As stated above, the subscription price of the " Medical News and Library" is 
One Dollar per annum in advance; and it is furnished without charge to all adv-ance- 
paying subscribers to the "American Journal of the Medical Sciences." 

in. 
THE MONTHLY ABSTRACT OF MEDICAL SCIENCE, 

The "Monthly Abstract" is issued on the first of every month, each number con- 
taining forty-eight large octavo pages, thus furnishing in the course of the year about 
six hundred pages. The aim of the Abstract will be to present a careful condensa- 
tion of all thatis new and important in the medical journalism of the world, and all 
the prominent professional periodicals of both hemispheres will be at the disposal 
of the Editors. To show the manner in which this plan has been carried out, a con- 
densed summary of the contents of the numbers from January to June, 1875, will be 
found subjoined. It will thus be seen that during the last six months it has contained — 

Twenty-three A.rticles on Anatomy and I'hysiology. 

Thirty-three " " Materia Medica and Therapeutists, 

Ninety-six " " Medicine, 

Ninety -tivo " " Surgery. 

Sixty-one " " Midicifery and G-yntBCology. 

Eleven <' " Medical J^arispr udence and loisicolngij 

Three " " Hygiene — 

making in all Three Hundred and Nineteen articles in six months, or at the rate of 
more than Six Hundred articles per annuni. 

The subscription to the " Monthly Abstract," free of postage, is Two Dollars 
and a Half a year, in advance. 

As stated above, however, it will be supplied in conjunction with the "American 
Journal of the Medical Sciences" and the "Medical News and Library," making 
in all about 'JVenty-one Hundred pages per annum, the whole /ree of postage, for 
Six Dollars a year, in advance. 

The first volume of the " Monthly Abstract," from July to December, 1874, can 
be had by those who desire to have complete sets, if early application be made, for 
$1 50, forming a handsome octavo volume of 300 pages, cloth. 

In this effort to bring so large an amount of practical information within the reach 
of every member of the profession, the publisher confidently anticipates the friendly 
aid of all who are interested in the dissemination of sound medical literature. He 
trusts, especially, that the subscribers to the "American Medical Journal" will call 
the attention of their acquaintances to the advantages thus offered, and that he will 
be sustained in the endeavor to permanently establish medical periodical literature 
on a footing of cheapness never heretofore attempted. 

PEEMIUM rOE NEW SUBSOEIBEES TO THE "JOUENAL." 
Any gentleman who will remit the amount for two subscriptions for 1876, one of 
which must be for a neio subscriber, will receive as a premium, free by mail, a copy of 
"Flint's Essays on Conservative Medicine" (for advertisement of which see p. 15), 
or of "Sturoes's Clinical Medicine" (see p. 14), or of the new edition of "Swaynk's 
Obstetric Aphorisms" (see p. 24), or of "Tanner's Clinical Manual" (see p. 5), 
or of "Chambers's Restorative Medicine" (see p. 16), or of "West on Nervous 
Disorders of Children" (see page 21). 

%* Gentlemen desiring to avail themselves of the advantages thus offered will do 
well to forward their subscrijjtions at an early day, in order to insure the receipt of 
complete sets for the year 1H7(), as the constant increase in the subscription list 
almost always exhausts the quantity printed shortly after publication. 

1^" The safest mode of remittance is by bank check or postal money order, drawn 
to the order of the undersigned. Where these are not accessible, remittances for the 
"Journal" may be made at the risk of the publisher, by forwarding in registered 
letters. Address, 

HENRY C. LEA, 
Nos. 706 and 708 Sansom St., Philadelphia, Pa. 



Henry C. Lea's Publications — {Dictionaries). 



jnUNOLISON {ROBLEY), M.D., 

Late Professor of Institutes of Medicine in Jefferson Medical ColUge, Philadelphia. 

MEDICAL LEXICON; A Dictionary of Medical Science: Con- 
taining a conci.ee explanation of the various Subjects and Terms of Anatomy, Physiology, 
Pathology, Hygiene, Therapeutics, Pharmacology, Pharniacy, Surgery, Obstetrics, Medical 
Jurisprudence, and Dentistry. Notices of Climate and of Mineral Waters; Formulae for 
Officinal, Empirical, and Dietetic Preparations; with the Accentuation and Etymology of 
the Terms, and the French and other Synonymes ; so as to constitute a French as well as 
English Medical Lexicon. A New Edition. Thoroughly Revised, and very greatly Mod- 
ified and Augmented. By Eichard J. Dunglison, M.D. In one very large and hand- 
some royal octavo volume of over 1100 pages. Cloth, $6 60 ; leather, raised bands, $7 60. 
{Just Issued.) 
The object of the author from the outset has not been to make the vrork a mere lexicon OT 
dictionary of terms, but to nfFord, under each, a condensed view of its vo.rious medical relations, 
and thus to render the work an epitome of the existing condition of medical science. Starting 
with this view, the immense demand which has existed for the work has enabled him, in repeated 
revisions, to augment its completeness and usefulness, until at length it has attained the position 
of a recognized and standard authority wherever the language is spoken. 

Special pains have been taken in the preparation of the present'edition to maintain this en- 
viable reputation. During the ten years which have elapsed since the hist revision, the additions 
to the nomenclature of the medical sciences have been greater than perhaps in any similar period 
of the past, and up to the time of his death the author labored assiduously to incorporate every- 
thing requiring the attention of the student or practitioner. Since then, the editor has been 
equally industrious, so that the additions to the vocabulary are more numerous than in any pre- 
vious revision. Especial attention has been bestowed on the accentuation, which will be found 
marked on every word. The typographical arrangement has been much improved, rendering 
reference much more easy, and every care has been taken with the mechanical execution. The 
work has been printed on new type, small but exceedingly clear, with an enlarged page, so that 
the additions have been incorporated with an increase of but little over a hundred pages, and 
the volume now contains the matter of at least four ordinary octavos. 
A book well known to our readers, and of wbich We are glad to see a new edition of this invaluable 



every American ought to be proud. When the learned 
author of the work passed away, probably all of us 
feared lest the book should not maintain its place 
iD the advancing science whose terms it defines. For- 
tunately, Dr. Kichard J. Dunglison, having a.«sisted his 
father in the revision of several editions of the work, 
and having been, therefore, trained in the methods and 
imbued with the spirit of the book, has been able to 
edit it, not in the patchwork manner .«o dear to the 
heart of book editors, so repulsive to the taste of intel- 
ligent book readers, but to edit it as a work of the kind 
should be edited — to carry it on steadily, without jar 
or interruption, along the grooves of thought it has 
travelled during its lifetime. To show the magnitude 
of the task which Dr. Dunglison has assumed and car- 
ried through, it is only necessary to stale that more 
than six thousand new subjects have been added in the 
present edition. Without occupying more space with the 
theme, we congratulate the editor on the successful 
completion of his labors, and hope hemay reap the well- 
earned reward of profit and honor. — Flnla. Med. Times, 
Jan. 3, 1874. 

About the first book purchased by the medical stu- 
dent is the Medical Dictionary. The lexicon explana- 
tory of technical terms is simply a sine qua non. In a 
science so extensive, and with such collaterals as medi- 
cine, it is as much a necessity also to the practising 
physician. To meet the wants of students and most 
physicians, the dictionary must be condensed while 
comprehensive, and practical while perspicacious. It 
was because Dunglison's met these indications that it 
became at once the dictionary of general use wherever 
medicine was studied in the English language. In no 
former revision have the alterations and additions been 
80 great. More than six thousand new subjects and terms 
have been added. The chief terms have been set in black 
letter, while the derivatives follow in small caps; an 
arrangement which greatly facilitates reference. We 
may safely confirm the hope ventured by the editor 
" that the work, which possesses for him a filial as well 
as an individual interest, will be found worthy a con- 
tinuance of the position so long accorded to it as a 
standard authority." — Cincinnati Clinic, Jan. 10, 1874. 



work, and to find that it has been so thoroughly revised, 
and so greatly improved. The dictionary, in its pre- 
sent form, is a medical library in itself, and one of 
which every physician should be possessed. — N. T. Med. 
Journal, Feb. 1874. 

With a history of forty years of unexampled success 
and universal indorsement by the medical profession of 
the western continent, it would be presumption in any 
living medical American to essay its review. No re- 
viewer, however able, can add to its fame; no captious 
critic, however caustic, can remove a single stone from 
its firm and enduring foundation. It is destined, as a 
colossal monument, to perpetuate the solid and richly 
deserved fame of Robley Dunglison to coming genera- 
tions. The large additions made to the vocabulary, we 
think, will be welcomed by the profession as supplying 
the want of a lexicon fully up with the march of sci- 
ence, which has been increasingly felt for some years 
past. The accentuation of terms is very complete, and, 
as far as we have been able to examine it, very excel- 
lent. We hope it may be the means of securing greater 
uniformity of pronunciation among medical men. — At- 
lanta Med. and Surg. Jvurn., Feb. 1S74. 

It would be mere waste of words in us to express 
jar admiration of a work which, is so universally 
and deservedly appreciated. The most admirabl* 
work of its kind in the English language. — OUasgow 
Medical Journal, January, 1866. 

A work to which there is no equal in the English 
language. — Edinburgh Medical Journal. 

Few works of the class exhibit a grander monument 
of patient research and of scientific lore. The extent 
of the sale of this lexicon is sufficient to testify to its 
asefulness, and to the great service conferred by Dr. 
Robley Dunglison on the profession, and indeed on 
others, by its issue. — London Lancet, May 13, 1865. 

It has the rare merit that it certainly has no rival 
in the English language for accuracy and extent of 
references. — London Medical Gatette. 



TJOBLYN {RICHARD D.), M.D. 



A DICTIONARY OF THE TERMS USED IN MEDICINE AND 

THE COLLATERAL SCIENCES. Revised, with numerous additions, by Isaac Hats, 
M.D., Editor of the "American Journal of the Medical Sciences." In one large royal 
I2mo. volume of over 500 double-columned pages; cloth, $1 60 j leather, $2 00. 
it Is the best book of definitions we have, and oQ«ht always to be apon the itudent's table.— Scmfft«r« 
Med and Surg. Journal. 



Henry (J. Lea's Publications — (Manuals). 



T>ODWELL {G.F.), F.B.A.S., S^r,. 

A DICTIONARY OF SCIENCE: Comprising Astronomy, Cliem- 

istry, Dynamics, Electricity, Heat, Hydrodynamics, Hydrostatics, Light, Magnetism, 
Mechanics, Meteorology, Pneumatics, Sound, and Statics. Preceded by an ~ 
History of the Physical Sciences. In one handsome octavo volume of 6S 
many illustrations : cloth, $5. 



on the 
pages, and 



WEILL [JOHN), M.D. 



a,nd 



RMITH [FRANCIS G.), M.D., 

Prof, of the Institutes of Medicine i^ the Unvo. of Penna. 

AN ANALYTICAL COMPENDIUM OF THE YARIOUS 

BRANCHES OF MEDICAL SCIENCE ; for the Use and Examination of Students. A 
new edition, revised and improved. In one very large and handsomely printed royal 12mo. 
volume, of about one thousand pages, with 374 wood cuts, cloth, $4; strongly bound in 
leather, with raised bands, $4 75. 

N. 0. Med. and Surg. 



The Compend of Drs. Neill and Smith is incompara- 
l»iy the most valuable work of its class ever published 
tn this country. Attempts have been made in various 
quarters to squeeze Anatomy, Physiology, Surgery, 
the Practice of Medicine, Obstetrics, Materia Medica, 
and Chemistry into a single manual; but the opera- 
tion has signally failed in the hands of all up to the 
advent of " Neill and Smith's' ' volume, which is quite 
a miracle of success. The outlines of tke whole are 
admirably drawn and illustrated, and the authors 
are eminently entitled to the grateful 'consideration 



if the student of every class.- 
Toiirnal. 

There are but few students or practitioners of me- 
(icine unacquainted with the former editions of this 
massuming though highly instructive work. The 
whole science of medicine appears to have been sifted, 
vs the gold-hearing sands of El Dorado, and the pre- 
cious fact.s treasured up in this little volume. Acom- 
plete portable library so condensed that the student 
may make it his constant pocket companion. — West- 
ern Lancet. 



JTARTSHORNE [HENRY), M. D., 

Professor of Hygiene in the University of Pennsylvania. 

A CONSPECTUS OF THE MEDICAL SCIENCES; containing 

Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practical Medicine, 
Surgery, and Obstetrics. Second Edition, thoroughly revised and improved. In one large 
royal 12mo. volume of Uiore than 1000 closely printed pages, with 477 illustrations on 
wood. Cloth, $4 25 ; leather, $5 00. {Lately Issued.) 
The work before us has already s uccessfuUy assert- 
ed its claim to the confidence aud favor of the profes- 
sion ; it but remains for us to say that in the present 
edition the whole work has been fully overhauled 
and brought up to the present sta(.us of the science. — 
Atlanta Med. and Surg. Journal, Sept. 187-1. 



The work is intended as an aid to the medical stu- 
dent, and as such appears to admirably fulfil its ob- 
ject by its excellent arvangemeni , the full compilation 
gf facts, the perspicuity aud tf^rseness of language. 



and the clear and instructive illustrations in some 
parts of the work. — American Journ. of Pharmacy, 
Philadelphia, July, 1S74. 

The volume will be found useful, not only to stu- 
dents, but to maay others who may desire to refresh 
their memories with the smallest possible expendi- 
ture of time. — N. Y. Med. Journal, Sept. 187-t. 

The student will tind this the most convenient and 
useful book of the kind on which he can lay his 
hand. — Pacific Med. and Surg. Journ., Aug. 1S74. 



MLD. 



T VDLO W [J. L. 
A MANUAL OP EXAMINATIONS upon Anatomy, Physiology, 

Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and 
Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised 
and greatly extended and enlarged. With 370 illustrations. In one handsome royal 
12mo. volume of 81 6 large pages, cloth, $3 25 ; leather, $3 75. 
The arrangement of thi s volume in the form of question and answer renders it especially suit- 
able for the office examin ation of students, and for those preparing for graduation. 



/TANNER [THOMAS HAWKES), M.B., ^c. 

A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAG- 

NOSIS. Third ^.meriean from the Second London Edition. Revised and Enlarged by 

Tilbury Fox, M. D., Physician to the Skin Department in University College Hospital, 

Ac. In one neat^olumesmall ]2mo., ofabout375 pages, cloth, $150. 

*i/f* By reference to the " Prospectus of Journal" on page 3, it will be seen that this work is 

offered as a premium foi r procuring new subscribers to the "American Journal op the Medical 

Sciences." 

Tlie objections commonly, and justly, urged against 
the general run of "compeuds," "conspectuses," and 
other aids to indolence, ai-e not applicable to this little 
volume, which contains in concise phrase Just thoHe 
practical details that are of most use in daily diag- 
nosis, but which the young practitioner finds it ditll- 
cult to carry always in his memory without some 
quickly accessible means of reference. Altogether, 
the book is one which we can heartily commend to 
those who have not opportunity for extensive read- 
ing, or who. having road much, still wish an occa- 
sional pracif" ' re,.,iuder. — -.V. Y. Med. Oazettc, Niv. 
10, 1870. 



Taken as a whole, It ih the most compact vade me- 
cum for the u.se of the ai Ivanced student and junior 
practitioner with which i 7e are acquainted. — Boston 
Med. and Surg. Journal , Sept. 22, 1870. 

It contains so much th at is valuable, presented in 
80 attractive a form, that it can hardly be spared 
even in the presence of m ore full and complete works. 
Its convenient size makos it a valuable companion 
to the courilry practitioner, and if conitantly car- 
ried by him, would ofloi i render him good service, 
and relieve many a doul .t and perplexity.— teaueJi- 
worth Med. Herald, Jul/ 1870. 



Henbt C. Lea's Publications — {Anatom}/). 



QR^T {HENRY), F.R.S., 

Lecturer on Anatomy at St. Oeorge'e Hospital, London. 

ANATOMY, DESCRIPTIYE AND SURGICAL. The Drawings by 

H. V. Carter, M. D., late Demonstrator on Anatomy at St. George's Hospital ; the Dissec- 
tions jointly by the Author and Dr. Carter. A new American, from the fifth enlarged 
and improved London edition. In one magnificent imperial octavo volume, of nearly 900 
pages, with 466 large and elaborate engravings on wood. Price in cloth, $6 00 ; lea- 
ther, raised bands, $7 00. (Just Issued.) 
The author has endeavored in this work to cover a more extended range of subjects than is cus- 
tomary in the ordinary text-books, by giving not only the details necessary for the student, bttt 
also the application of those details in the practice of medicine and surgery, thus rendering it both 
a guide for the learner, and an admirable work of reference for the active practitioner. The en- 
gravings form a special feature in the work, many of them being the size of nature, nearly all 
original, and having the names of the various parts printed on the body of the cut, in place of 
figures of reference, with descriptions at the foot. They thus form a complete and splendid series, 
which will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve to 
refresh the memory of those who may find in the exigencies of practice the necessity of recalling 
the details of the dissecting room ; while combining, as it does, a complete Atlas of Anatomy, witi 
a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of 
essential use to all physicians who receive students in their offices, relieving both preceptor and 
pupil of much labor in laying the groundwork of a thorough medical education. 

Notwithstanding the enlargement of this edition, it has been kept at its former very moderate 
price, rendering it one of the cheapest works now before the profession. 

The illuetrations are beautifully execnted, and ren- [ From time to time, as snccessi-re editions bave ap- 
der this work an indispensable adjunct to the library peared, we have had much pleasure in e:xpre3sfnjj 
of the surgeon. This remark applies with great force i the general judgment of the wonderful excellence ol 
to those surgeons practising at a distance from our I Gray's Anatomy. — Cincinnati Lancet, July, 1870. 
lai-ge cities, as the opportunity of refreshing their . Altogether, it is nnquestionablv the most cottpl&t» 
memory by actual dissection is not always attain- a^^ serviceable textbook in anatomy that has ever 
able. — Canada Med. Journal, Aug. 1S70. | been presented to the student, and forms a striking 



The work is too well known and appreciated by th 
profession to need any comment. No medical man 
can afford to be without it, if its only merit were to 
serve as a reminder of that which so soon becomes 
forgotten, when not called into frequent use, viz., the 
relations and names of the complex organism of the 
human body. The present edition is much improved. 
—Ooliforn'in Med. Gazette, July, 1S70. 



contrast to the dry and perplexing volumes on the 
same subject through which their predecessors strug- 
gled in days gone hj.—N. ¥. Med. Record, June 15, 
1870. 

To commend Gray'B Anatomy to the raedical pro- 
fession i.< almost as much a work of supererogation 
as it woiuld be to give a favorable notice of tbe Biblfl 
n the religious press. To say that it is the most 



Gray's Anatomy has been go long the standard of i complete and conveniently arranged test-book of itJ 
perfection with every student of anatomy, that we kind, is to repeat what each generation of student* 
need do no more than call attention to the improve- | has learned as a tradition of the elders, and verified 
went in tlie present edition.— Deiroii Review of Med. by personal experience.— if Y. Med. Gazette, Dec. 
and Pharm., Aug. 1S70. I 17, 1870. 



^MITB {HENRY H.), M.D., and TJORNER { WILLIAM E.), M.D., 

Prof, of Surgery in the Univ. ofPenna., *c. LateProf. of Anatomy in the Univ. ofPenna.,At, 

AN ANATOMICAL ATLAS, illustrative of the Structure of tlie 

Human Body. In one volume, large imperial octavo, cloth, with abont six handred and 

fifty beautiful figures. $4 60. 
The plan of this Atlas, which renders it so pecn- I the kind that has yet appeared; and we must add, 
liarly convenient for the student, and its superb ar- | the very beautiful manner in which it is "got up," 
tistical execution, have been already pointed out. We j is so creditable to the country as to be flattering t« 
mutt congratulate the student upon the completion our n&t\on&\^riiiQ.— Ameria.in MedicalJoternai. 
of this Atlas, as it is the most convenient work of I 



UHA RPE Y { WIJ JjIA M),M.D., and Q DA IN {JONES ^' RICHARD) . 
HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph 

Leidt, M.D., Professor of Anatomy in the University of Pennsylvania. Complete in t'wo 
large octavo volumes, of about 1300 pages, with 511 illustrations; cloih, $6 00. 
The very low price of this standard work, and its completeness in all departments of tbe subject, 
should command for it a place in the library of all anatomical students. 



LTODGES {RICHARD 31.), M.D., 

Late Demonstrator of Anatomy in the Medical Department of Harvard University. 

PRACTICAL DISSECTIONS. Second Edition, thoroughly revised. In 

one neat royal 12mo. volume, half-bound, $2 00. 
The object of this work is to present to the anatomical student a clear and concise description 
of that which he is expected to observe in an ordinary course of dissections. The author has 
endeavored to omit unnecessary details, and to present the subject in the form which many years' 
experience has shown him to be the most convenient and intelligible to the student. In the 
revision of the present edition, he has sedulously labored to render the volume more worthy of 
the favor with which it has heretofore been received. 



<)K«t,K SM-j-.Li.M. AJNATOMY AKD HISTOLOGY. I In 2 vols. Svc, of over 1000 pares, with 
Eighth edition, extensively revised and modified. I 300 wood-cuts ; eloth, $6 60. 



Henry C. Lea's Publications— (^na^omy). 



-mriLSON (ERASMUS), F.B.S. 

A SYSTEM OF HUMAN A:NrATOMY, General and Special. Edited 

by W.H. Q-oisRECHT, M.D., Professor of General and Surgical Anatomy in tke Medical Col- 
lege of Ohio. Illustrated with three hundred and ninety-seven engravings on wood. In 
one large and handsome octavo volume, of over 600 large pages; cloth, $4 00; leather, 
$5 00. 
The publisher trusts that the well-earned reputation of this long-established favorite will be 
more than maintained by the present edition. Besides a very thorough revision by the author, it 
has been most carefully examined by the editor, and the efforts of both have been directed to in- 
troducing everything which increstsed experience in its use has suggested as desirable to render it 
a complete text-book for those seeking to obtain or to renew an acquaintance with Human Ana- 
tomy. The amount of additions which it has thus received may be estimated from the fact that 
the present edition contains over ono-fourth more matter than the last, rendering a smaller type 
and an enlarged page requisite to keep the volume within a convenient size. The author has not 
only thus added largely to the work, but he has also made alterations throughout, wherever there 
appeared the opportunity of improving the arrangement or style, so as to present every fact in its 
most appropriate manner, and to render the whole as clear and intelligible as possible. The editoj 
has exercised the utmost caution to obtain entire accuracy in the text, and has largely increased 
the number of illustrations, of which there are about one hundred and fifty more in this edition 
than in the last, thus bringing distinctly before the eye of the student everything of interest oi 
Importanco. 

fJEATH [GHRISTOPHER], F. R. G. S., 

*-^ Teacher of Operative Surger-y in Uiiiversiiy College, London. 

PRACTICAL ANATOMY: A Manual of Dissections. From the 

Second revised and improved London edition. Edited, with additions, by W. VV. Kesn, 
M.D., Lecturer on Pathological Anatomy in the JeiFerson Medical College, Philadelphia. 
In one handsome royal 12mo. volume of 578 pages, with 247 illustrations. Cloth. $3 60 j 
leather, $4 00. {Lately PiMisked.) 



Dr. Keen, the American editor ol this work, in his 
preface, says : "In presenting this American edition 
of 'Heath's Practical Anatomy,' I feel that I have 
been instrumental in supplying a want long felt for 
a real dissector's manual," and this assertion of its 
Qditor we deem is fully justified, after an examina- 
tion of its contents, for it is really an excellent work. 
Indeed, we. do not hesitate to say, the best of its class 
with which we are acquainted ; resembling 'Wilson 
In terse and clear description, excelling most of the 
ao-cttiled practical anatomical dissectors in the scope 
of the subject and practical selected matter, . . . 
la reading this work, one is forcibly impressed with 
the great pains the author takes to impress the sub- 
ject upon the mind of the student. Re is full of rare 
and pleasing little devices to aid memory in main- 



taining its hold upon the slippery slopes of anatomy. 
—St. Louis Med. and ISurg. Journal, Mar. 10, 1871. 

It appears to us certain that, as a guide in dissec- 
tion, and as a work containing facts of anatomy in 
brief and easily understood form, this manual is 
complete. This work contains, also, very perfect 
illustrations of parts which can thus be more easily 
inderstood and studied; in this respect it compares 
favorably with works of much greater pretension. 
Such manuals of anatomy are always favorite works 
with medical students. We would earnestly recom- 
mend this one to their attention; it has excellences 
which make it valuable as a guide in dissecting, as 
well as in studying anatomy. — Buffalo Medical and 
Surgical Journal, Jan. ISli. 



'DELLAMY{E.), F.R.C.S 

THE STUDENT'S GUIDE TO SURGICAL ANATOMY: A Text- 

Book for Students preparing for their Pass Examination. With engravings on wood. In 
ono handsome royal I2mo. volume. Cloth, $2 25. {Just Issued.) 
'We welcome Mr. Bellamy's work, as a contribu- 
tion to the study of regional anatomy, of equal value 
to the student and the surgeon. It is written in a 
clear and concise style, and its practical suggestions 
add largely to the interest attaching to its technical 
details — Chicago Med. Examiner, March 1, lS7-i. 



'We cordially congratulate Mr. Bellamy upon hav- 
ing produced it. — Med. Times and Gaz. 



We cannot too highly recommend it. — Studenfs 
Journal. 

Mr. Bellamy has spared no pains to produce a real- 
ly reliable student's guide to surgical anatomy — one 
which all candidates for surgical degrees may con- 
sult with advantage, and which posseses much ori- 
ginal matter. — Med. fress and Circular. 



JlfACLISE [JOSEPH). 

SURGICAL ANATOMY. By Joseph Maclisb, Surgeon. In one 

volume, very large imperial quarto; with 68 large and splendid plates, drawn in the best 

style and beautifully colored, containing 190 figures, many of them the size of life; together 

with copious explanatory letter-press. Strongly and handsomely bound in cloth. Price 

$14 00. 

We know of no work on surgical anatomy which | ijions have hitherto, we think, been given. 'While 

♦an compete with it. — Lancet. the operator is shown every vessel and nerve where 

The work of MacUse on surgical anatomy is of the '-n operation is contemplated, the exact anatomist 18 

highest value. In some respects it is the best publi- refreshed by those clear and dintiuci dissecuous. 



cation of its kind we have seen, and is worthy of a 
place in the libiary of any medical man, while the 
student could .-scarcely make a better investment than 
this. — The Western Journalo/Medicineeind Surgery 
No such lithographic illustralione of surgical re 



which every one must appreciate who has a particle 
of onthusiasm. The English medical press has quite 
exhausted the words of praise, in recommending this 
admirable treatise. — Boston Med. and Surg. Jaurn. 



H 



ARTSHORNE [H ENR F) , AI. D., 

Prcfessor uf HijyU-.ne, etc , in the Univ. ofVenna. 

HANDBOOK OF ANATOMY AND PlIYSIOLOGY. Second Edi- 
tion, revised. In one royal 12mo. volume, with 2-0 woodcutp; cloth, $1 75. {Just Isf-ued.^ 



Henby C. Lea's Publications — (Physiology). 



MARSHALL (JOHN), F. R. S., 

■**^ Professor of Stirgery in University College, London, Ac. 

OUTLINES OF PHYSIOLOGY, HUMAN AND COMPARATIYE. 

With Additions by Francis Guknet Smith, M. D., Professor of the Institutes of Medi- 
cine in the University of Pennsylvania, Ac. With numerous illustrations. In one large 
and handsome octavo volume, of 1026 pages, cloth, $6 50 ; leather, raised bands, $7 50. 
In fact, in every re.-^pect, Mr. Marshall has present- 
ed us with a most complete, reliable, and scientific 
work, and we feel that it is worthy our warmes't 
eommendation. — St. Louis Med. Reporter, Jan. 1869. 

We doubt if there is in the English language any 
compend of physiology more useful to the student 



tive, with which we are acquainted. To speak o! 
this work in the terms ordinarily used on such occa- 
sions would not be agreeable to ourselves, and would 
fail to do justice to its author. To write such a book 
requires a varied and wide range of knowledge, con- 
siderable power of analysis, correct judgment, skill 
in arrangement, and conscientious spirit. — London 
Lancet, Feb. 22, 1868. 

I. quite fulfils, in our opinion, the author's design I '^.''"^^^^^'^'/^t^f' more accomplished anatomiste 
of making it truly «dMca<ionann its character-which ^"'i physiologists than the distnguished professor of 
.. _..,,„°„ .!,„ i,!_v„„. j„.i„„ .!,„. „„„ v„ I surgery at University College; and he has long en- 
joyed the highest reputation as a teacher of physiol- 
ogy, possessing remarkable powers of clear exposition 
and graphic illustration, We have rarely the plea.- 



-iS(. Louis Med. and Surg. Journal, \ 



than this work. 
Jan. 18 



Is, perhaps, the highest commendation that can 
asked. — Am. Journ. Med. Sciences, Jan. 1869, 

We may now congratulate him on having com- 



pleted the latest as well as the best summary of mod- sure of being able to recommend a text-book so unre- 
ern physiological science, both human and compara- ' B6XYBd.\yti6thU.— British Med. Journal, Jap.25,186S. 



C 



ARP ENTER [WILLIAM B.), M.D., F.R.S., 

Examiner in Physiology and Comparative Anatomy in the University of London. 

PRINCIPLES or HUMAN PHYSIOLOGY; with their chief appli- 

cations to Psychology, Pathology, Therapeutics, Hygiene and Forensic Medicine. A new 
American from the last and revised London edition. With nearly three hundred illustrations. 
Edited, with additions, by Francis Gurnet Smith, M. D., Professor of the Institutes of 
Medicine in the University of Pennsylvania, &c. In one very large and beautiful octavo 
volume, of about 900 large pages, handsomely printed; cloth, $5 50; leather, raised banda, 
$6 60. 

We doubt not it is destined to retain a strong hold 
on public favor, and remain the favorite text-book in 
our colleges. — Virginia Medical Journal. 



With Dr. Smith, we confidently believe "that the 
present will more than sustain the enviable reputa- 
tion already attained by former editions, of being 
one of the fullest and most complete treatises on the 
gubject in the English language." We know of none 
from the pages of which a satisfactory knowledge of 
the physiology of the human organism can be as well 
obtained, none better adapted for the use of such as 
take up the study of physiology in its reference to 
the institutes and practice of medicine. — Am. Jour. 
Med. Sciences. 



The above is the title of what is emphatically th« 
great work on physiology ; and we are conscious that 
it would be a useless eifort to attempt to add any- 
thing to the reputation of this invaluable work, and 
can only say to all with whom our opinion has any 
iufluence, that it is our authority. — Atlanta Med. 
Journal. 



or THE SAME AUTHOR. 

PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New Ameri- 

can, from the Fourth and Revised London Edition. In one large and handsome octavo 
volume, with over three hundred beautiful illustrations Pp.762. Cloth, $6 00. 
As a complete and condensed treatise on its extended and important subject, this work becomes 
a necessity to students of natural science, while the very low price at which it is offered places it 
within the reach of all. 



l^IRKES [WILLIAM SENHOUSE), M.D. 

A MANUAL OP PHYSIOLOGY. Edited by W. Morrant Baker, 

M.D., F.R.C.S. A new American from the eighth and improved London edition. With 
about two hundred and fifty illustrations. In one large and handsome royal 12mo. vol- 
ume. Cloth, $3 25; leather, $3 76. {Lately Isstied.) 
Kirkes' Physiology has long been known as a concise and exceedingly convenient text-book, 
presenting within a narrow compass all that is important for the student. The rapidity with 
which successive editions have followed each other in England has enabled the editor to keep it 
thoroughly on a level with the changes and new discoveries made in the science, and the eighth 
edition, of which the present is a reprint, has appeared so recently that it may be regarded as 
the latest accessible exposition of the subject. 



Oa the whvle, there is very little in the book 
which either the student or practitioner will notflud 
of practical value and consistent with our present 
knowledge of this rapidly changing science ; and we 
have no hesitation in exprefsiug our opinion that 
this eighth edition is one of the best handbooks on 
physiology which we have in our language. — N. Y. 
Med. Record, April 15, 1873. 

This volume might well be used to replace many 
of the physiological text-books in use in this coun- 
try. It represents more accurately than the works 
of Dalton or Flint, the present state of our knowl- 
edge of most physiological questions, while it ie 
much less bulky and far more readable than the lar- 



ger text-books of Carpenter or Marshall. The book 
is admirably adapted to be placed In the hands of 
students. — Boston Med. and Surg. Journ., April 10, 
1873. 

In its enlarged form it is, in our opinion, etiU the 
best book on physiology, most useful to the student. 
—Phila. Med. Times, Aug. 30, 1873. 

This is undoubtedly the best work for students of 
physiology extant. — Cincinnati Mtd. News, Sept. '73. 

Il more nearly represents the present condition of 
physiology than any other text-book on the subject.— 
Detroit Rev. of Med. Pharm., Nov. 1873. 



HsNaY C. Lea's Tv-bilioatioius— (Physiology). 



nALTON {J. C), M.D., 

-^^ Professor of Physiology in the College of Physicians and Surgeons, New York, Sec. 

A TREATISE ON" HUMAISr PHYSIOLOUY. Designed for the use 

of Students and Practitioners of Medicine. Sixth edition, thoroughly revised and enlarged, 
with three hundred and sixteen illustrations on wood. In one very beautiful octavo vol- 
ume, of over 800 pages. Cloth, $5 50; leather, $6 50. {Noto Ready.) 

From the Preface to the Sixth Edition. 

In the present edition of this book, while every part has received a careful revision, the ori- 
ginal plan of arrangement has been changed only so far as was necessary for the introduction of 
aew material. Although the whole field of physiology has been cultivated, of late years, with 
unusual industry and success, perhaps the most important advances have been made in the two 
departments of Physiological Chemistry and the Nervous System. The number and classification 
of the proximate principles, more especially, and their relation to each other in the process of 
nutrition, have become, in many respects, better understood than formerly : though it is evident 
that this fundamental part of physiology is to receive, in the future, modifications and additions 
of the most valuable kind. 

The additions and alterations in the text, requisite to present concisely the growth of positive 
physiological knowledge, have resulted in spite of the author's earnest efforts at condensation, 
in an increase of fully fifty per cent, in the matter of the work. A change, however, in the ty- 
pographical arrangement has accommodated these additions without undue enlargement in the 
bulk of the volume. 

The new chemical notation and nomenclature are introduced into the present edition, as hav 
ing now so generally taken the place of the old, that no confusion need result from the change. 
The centigrade system of measurements for length, volume, and weight, is also adopted, these 
measurements being at present almost universally employed in original physiological investiga- 
tions and their published accounts. Temperatures are given in degrees of the centigrade scale, 
usually accompanied by the corresponding degrees of Fahrenheit's scale, inclosed in brackets. 
New York, September, 1875. 

A few notices of the previous edition are subjoined. 



The fifth edition of thi.s truly valuable work on 
Hamaa Physiology comes to us with many valuable 
improvements and addi(;ioas. As a test-book of 
physiology the work of Prof. Dalton has long been 
well known as one of the best which could be placed 
'fa. the hands of student or practitioner. Prof. Dalton 
has, in the several editions of his work heretofore 
published, labored to keep step with theadvancemont 
in science, and the last edition shows by its improve- 
ments on former ones that he is determined to main- 
tain the high standard of his work. We predict for 
She present edition increased favor, though this work 
has long been the favorite standard.— .Bw/aJo Med. 
and Surg. Journal, April, 1872. 

An extended notice of a work so generally and fa- 
vorably known as this is unnecessary. It is justly 
regarded as one of the most valuable text-books on 
the subject in the English language. — St. Louie Med. 
Archives, May, 1872. 

We know no treatise in physiology so clear, com- 
plete, well assimilated, and perfectly digested, as 
Dalton's. He never writes cloudily or dubiously, or 
la mere quotation. He assimilates all his material, 
aad from it construets a homogeneous, transparent 



argument, which is always honest and well informed, 
and hides neither truth, ignorance, nor doubt, so far 
as either belongs to the subject in hand. — Brit. Med. 
Journal, March 23, 1872. 

Dr. Dalton's treatise is well known, and by many 
highly esteemed in this country. It is, indeed, agood 
elementary treatise on the subject it professes to 
teach, and may safely be put into the hands of Eng- 
lish students. It has one great merit — it is clear, and, 
on the whole, admirably illustrated. The part wa 
have always esteemed most highly is that relating 
to Embryology. The diagrams given of the various 
stages of development give a clearer view of the sub- 
ject than do those in general use in this country ; and 
the test may be said to be, upon the whole, equally 
clear. — London Med. Times and Gazette, March 23, 
1872. 

Professor Dalton is regarded] ustly as the authority 
in this country on physiological subjects, and the 
fifth edition of his valuable work fully justifies th« 
exalted opinion the medical world has of his labors. 
This last edition is greatly enlarged.— KtVciwia Olin- 
ical Record, April, 1872. 



B 



UNGLISON [ROBLEY), M.D., 

Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. 

HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and 

extensively modified and enlarged, with five hundred and thirty-two illustrations. In two 
large and handsomely printed octavo volumes of about 1500 pages, cloth, $7 00. 



J EHMANN [G. G.). 

PHYSIOLOGICAL CHEMISTRY. Translated from the second edi- 

tion by Gkoroe E Day, M. D., F. R. S., ka.. edited by R. E. Rogers, M. D., Professor of 
Chemistry in the Medical Department of the University of Penn.«ylvania, with illustrationu 
selected from Funke's Atlas of Physiological Chemistry, and an Appendix of plates. Com- 
plete in two large and handsome octavo volumes, containing 1200 pages, with nearly two 
hundred illustrations, cloth, $6 00. 

TOY TffE SAME AUTHOB. 

MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the 

German, with Notes and Additions, by J. Ciibston Morris, M. D., with an Introductory 
Essay on Vital Force, by Professor Samubl Jackson, M. D., of the University of Pennsyl- 
vania. With i]lu.stration8 ou wood. In one very handsome octavo volume of 336 pages, 
olntfa, $2 26. 



10 



Henry C. Lea's Publications — {Chemistry). 



A TTFIELD {JOHN), Ph. D., 

Prn/tx.inr of Prncticnl Che.miifrj/ to the. Phnt-manmUirvrl Bociety of Orent Britain, &e. 

CHEMISTRY, GENERAL. MEDICAL. AND PHARMACEUTICAL ; 

including the Chemistry of the U. S. Pharmacopoeia. A Mannal of the Gener.nl Principles 
of the Science, and their Application to Medicine and Pharmacy. Fifth Edition, revissd 
hy the author. In one handsome royal 12mo. volume; cloth, $2 76; leather, $3 25. 
(Lately Ifsned.) 



No other American piiTiliration -with which we are 
acquainted covers the same ground, or does it so well. 
In addition to an admirable expose of tho facts and 
principles of general elementary chemistry, the au- 
thor has presented ns with a condensed mpssof prac- 
tical matter, just such as the medical student and 
practitioner ne^iU.—Cincimirdi LnnceX, Mar 1S74. 

We commend the work bearlily as one of the best 
text-books extant for the medical student. — Detroit 
Sev. of Med. and Pharm., Feb. 1S72. 

The best work of the kind in the English language. 
— N. Y. PaychologicalJovrnal, Jan. 1S72. 

The work is constructed with direct reference to 
the wants of medical and pharmaceutical student.'* ; 
and, although an English work, the points of ditfer 
ence between the British and United States Pharma- 
copceias are indicated, makinj; it as useful here as in 
England. Altogether, the book Is one we can heart- 
llv recommend to practitioners as well as students. 
—N. T. Med. Journal, Dec. 1871. 

It differs from other text-hooks in the following 
particulars: first, in the exclusion of matter relating 
to compounds which, at present, are only of interest 
to the scientific chemist; secondly, in containing the 
chemistry of every substance recognized officially or 
In general, as a remedial agent. It will be found a 
most valuable book for pupils, a.«.8istants, and others 



engaged in medicine and pharmacy, and we heartily 
commend it to onr readers. — Canada Lancet, Oct. 

1871. 

When the original Engli.sh edition of this work was 
published, we had occasion to express our high ap- 
preciation of its worth, and also to review, in con- 
siderable detail, the main features of the book. Ab 
the arrangement of snbjects, and the main part of 
the text of the present edition are similar to the for- 
mer publication, it will be needless for us to go over 
the ground a second time ; we may. howevHr, call at- 
tention to a marked advantage possessed by the Ame- 
rican work— we allude to the introduction of th« 
chemistry of the preparations of the United States 
Pharmacopoeia, as well as that relating to the British 
authority. — Canadian Phnrmacetdical Journal, 
Nov. 1871. 

Chemistry has borne the name of being a hard sub- 
ject to master by the student of medicine, an^ 
chiefly because so much of it consists of componnda 
only of intereattothe scientific chemist ; in this work 
such portions are modified or altogether left out, and 
in thearrangernentofthesubiect-matterof the work, 
practical utility is sought after, and we think fully 
attained. We commend it for its clearness and order 
to both teacher and pupil. — Oregon Med. and Surp. 
Reporter, Oct. 1S71. 



lOWNES (GEORGE), Ph. D. 

A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and 

Practical. With one hundred and ninety-seven illustrations. A new American, from the 
tenth and revised London edition. Edited by "Robert Bridges, M. D. Ib one large 
royal 12mo. volume, of about 850 pp., cloth, $2 75 ; lerUher, .§3 25. (Latelif Issued.) 



This work is so well known that it seems almost 
superfluous for us to speak about it. It has been a 
favorite text-book with medical students for years, 
and its popularity has in no respect diminished. , 
Whenever we have been consulted by medical stu- 
dents, as has frequently occurred, what treatise on 
cliemistry they should procure, we have always re- 
commended Fownes', for we regarded it as the best. 
There is no work that combines so many excellen- 
ces. It is of convenient size, not prolix, of plain 

perspicuous diction, contains all the most recent its old place as the most successful of text-boolts.- 
discoveries, and is of moderate ^ricB.— Cincinnati Indian Medical ffazeUe, Jan. 1, 1869 
Med. Repertory, Aug. 1899. It will continue, as heretofore, to hold the first rank 

Large additions have been made, especially in the is a text-book for students of Hjedicia*.— CR«"««^« 
department of organic chemistry, and we fenow of no Med. ExamiriSr, Aug. l&SS. 



work that has greater claims on the physicia.o, 
itist, or student, than this. We cheerful Jty 
recommend it as the best text-book on elementary 
chemistry, and bespeak for it the careful aftentioa 
■>f students of pharmacy. — Uhicttffo Phnrmaeist, kng. 

Here is a new editios which has been long wateb&d 
for by eager teachers of chemistry. In its new garb, 
and under the editorship of Mr. Watts, it has resumed 







DLTNG [WILLIAM), 

Lei^turer on Chemistry at St. Bariholn'me-?ff's IIo.tpital, Ac. 

A COURSE OF PRACTICAL CHEMISTRY, arranged for the Use 

of Medical Students. With Iliustrations. yrorc the Fourth and Revised London Editjoa. 
In one neat royal 12mo. volume, cloth, %2. . 



6 CALLOWAY (ROBERT), F.G.S., 
' Prof, of Aiyplied Che-mistry in the Royal College of Sfneneefor Ireland, &e. 

A MANUAL OF QUALITATIVE ANALYSIS. From the Fifth Loii- 

don Edition. In one neat royal 12mo. volume, with illustrations; cloth, $3 50. {Jtt.ii 
Issved.) 
The success which has carried this work through repeated editions in England, sad its adopiiom 
as a text-book in several of the leading institutions in this oountry, show that the author has suc- 
ceeded in the endeavor to produce a sound practical manaal and book of reference for the che- 
mical student. 

Prof Galloway's books are deservedly in high | We regard this volnrae as a valuable addition to 
esteem, and this American reprint of the fifth edition the chemical text-books, and as particularly calci 



(1860) of his Manual of Qualitative Analysis, will be 
acceptable to many American students to whom the 
Bngli-;h edition is not accessible. — Ata. Jour, of Sci- 
♦Mce and Arts, Sapt. i672. 



lated to instruct the student in analytical researches 
of the inorganic compounds, the important vegetable 
acids, and of compounds and various secretions a.ai 
excretions of anisaal origia. — A}n. Journ. of PharKK, 
S&-pi. 1S73. 



Henry C. Lea's Publications — (ffkemi&try). 



11 



J>LOXAM (C. L.), 

■^^ Professor of Chemistry in King's College, London. 

CHEMISTRY, INORGANIC AND ORGANIC. From the Second Lon- 
don Edition. In ooe very handsome octavo volume, of 700 pages, with about 300 illustTa- 
tions. Cloth, $4 00 ; leather, $5 00. (Lately Issued.) 
It has been the author's endeavor to produce a Treatise on Chemistry sufficiently comprehen- 
K.ve for those studying the science as a branch of general education, and one which a student 
Eiay use with advantage in pursuing his chemical studies at one of the colleges or medical schools. 
The special attention devoted to Metallurgy and some other branches of Applied Chemistry renders 
the work especially useful to those who are being educated for employment in manufacture. 

have Iq this work a complete and most excel- , experiment have been worked up with especial care, 



lent text-book for the use of schools, and can heart- 
ily recommeod it as such. — Boston Med. and Surg. 
J-ourn., May 28, 187-4. 

Of all the numerous vrorfes upon elementary chem- 
istry that have been published within the last few 
years, we can point to none that, in fulness, accaracy, 
sind simplicity, can surpass this; while, in the nnm- 
berand detailed descriptions of experiments, as also 
in the profuaeness of its illustrations, we believe it 
stands above any similar work pub) ished in this coun- 
try The statements made are clear and con- 
cise, and every step proved by an abundance of ex- 
periments, which excite our admiration as much by 
Sheir simplicity as by their direct conclusiveness. — 
Chicago Med. Examiner, Nov. 15, 1873. 

It is seldom that in the same compass so complete 
and interesting a compendium of the leading facts of 
chemistry is oQ^T&d..— Druggists' Circular, Nov. '73. 

Tiie above is the title of a work which we can most 
eonscientioasly recommend to students of chemistry. 
It is as easy as a work on chemistry could be made, 
at the same lime tkat it presents a full acco ant of th at 
science as it now stands. We have spoken of the 
workas admirably adapted to the wants of students ; 
It is quite as well suited to the requirements of prac- 
titioners who wish to review their chemistry, or have 
occasion to refrash their memories on any point re- 
lating to it. In a word, it is a book to be read by all 
who wish to know what is the chemistry of the pre- 
sent A&y.—Amei-ican Practitioner, Nov. 1873. 



Among the various works upon general chemistry 
issued, we know of none that will supply the average 
wants of the student or teacher better than this.— 
Zndiana Jotirn. of Med., Nov. 1873. 

We cordially welcome this American reprint of a 
work which has already won for itself so substantial 
a reputation ia England. Professor Bloxam has con- 
densed into a wonderfully small com jass all the im- 
portant principles and facts of chemical science. 
Thoroughly imbued with an enthusiastic love for the 
science he expounds, he has stripped it of all need- 
less technicalities, and rounded out its hard outlines 
by a fulness of illustration that cannot fail to attract 
and delight the student. The details of illustrative 



A many of the experiments described are both i 
and striking. — Detroit Mev. of Med. and Pharm., 
Nov. 1873. 

One of the best text-books of chemistry yet pub- 
lished. — Chicago Med. Journ., Nov. 1873. 

This is an excellent work, well adapted for the be- 
ginner and the advanced student of chemistry. — Am. 
Jonrn. of Pharm., Nov. 1873. 

Probably the most valuable, and at the same time 
practical, text-book on general chemistry extant ia 
our language. — Kansas- City Med. Journ., Dec. 1S73. 

Prof. Bloxam possesses pre-eminently the inestima- 
ble gift of perspicuity, it is a pleasure to read his 
books, for he is capable of making very plain what 
other authors frequently have left very obscure. — 
Va. Clinical Record, Nov. 1S73. 

It would be ditacult for a practical chemist and 
teacher to find any material fault with this most ad- 
mirable treatise. The author has given us almost a 
cyclopedia within the limits of acon^enientvolume, 
and has done so without penning the useless para- 
graphs too commonly making up a great part of the 
bulk of many cumbrous works. The progressive sci- 
entistis not disappointed when he looks for the record 
of new and valuable processes and discoveries, while 
the cautious conservative does not find its pages mo- 
nopolized by uncertain theories and speculations. A 
peculiar point of excellence is the crystallized form of 
expression in which great truths are expressed in 
very short paragraphs. One is surprised at the brief 
space allotted to an important topic, and yet, after 
reading it, he feels that little, if any more, should 
have been said. Altogether, it is seldom you see & 
text-book so nearly faultless.— OtitcmjiaW Lancet 
Nov. 1873. 

Pri)fessor Bloxam has given us a most excellent 
and useful practical treatise. His 666 pages are 
crowded with facts and experiments, nearly all well 
chosen, and many quite new, even to scientific men. 
. . . It is astonishing how much information he oftea 
conveys in a few paragraphs. We might quote fifty 
instances of this. — Chemical News. 



JATOHLER AND FITTIG. 

'^ OUTLINES OP ORGANIC CHEMISTRY. Translated with Ad- 
ditions from the Eighth German Edition. By Ira Remsen, M.D., Ph.D., Professor of 
Chemistry and Physics in Williams College, Mass. In one handsome volume, royiil 12mo. 
of 550 pp., cloth, $3. 
As the numerous editions of the original attest, this work is the leading tert-bookand standard 
authority throughout Germany on its important and intricate subject — a position won for it by 
the clearness and conciseness which are its distinguishing ehn.racteristics. The translation has 
been e.xecuted with the approbation <if Profs. Wbhler and Fittig, and numerous additions and 
alterations have been introduced, so as to render it in every respect on a level with the most 
advanced condition of the science. 

^O WMAN (JOHN E.),M. D. 

PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Edited 

byC.L. Bloxam, Professor of Practical Chemi.stry in King's College, London. Sixth 
American, from the fourth and revised English Edition. In one neat volume, royal 12mo., 
pp. 351, with numerous illustrations, cloth, $2 25. 
^Y THE SAME AUTHOR. {LaUlij Issned.) 

INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING 

ANALYSIS. Sirth American, from the sixth and revised London edition. With numer- 
ous illustrations. In one neat vol., rojal 12mo., cloth, $2 25. 

eSiPP'R TKCHNOLOOT ; or Chemistry Applied tol 

j the Arte, and to Manufactures. Wlih American 

additions, by Prof. Waltb« K. Jonssoy. In two 



very handsome octavo volain< 
engravisgs, eloth, $6 00 



12 Heney C. Lea's Publications— (ifai. Med. and Therapeutics). 



PARRISH {EDWARD), 
Late Professor of Materia Medica in the Philadelphia College of Pharmacy . 

A TREATISE ON PHARMACY. Designed as a Text-Book for the 

Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and 
Prescriptions. Fourth Edition, thoroughly revised, hy TnoMAS S. Wieoand^ In one 
handsome octavo volume of 977 pages, with 280 illustrations ; cloth. ^5 60 ; leather, $6 60. 
(Lately Issued.) 
The delay in the appearance of the new U. S. Pharmacopoeia, and the sudden death c^ the au- 
thor, have postponed the preparation of this new edition heyond the period expected The notes 
and memoranda left by Mr. Parrish have been placed in the hands of the editor, Mr. Wiegand, 
who has labored assiduously to embody in the work all the improvements of pharmaceutical sci- 
Tnce which have been introduced during he last ten years. It is therefore hoped that the new 
edition will fully maintain the reputation which the volume has heretofore enjoyed as a standard 
text-book and work of reference for all engaged in the preparation and dispensing of medicines. 
Of Br Parrish's great work on pharmacy it only j an honored place on our own booksh.lves.-DuWin 
remains to be said that the editor ha. accomplished Med. Press and Circular, Ang. 12, 1874. 
his work so well as to maintain, in this fourth edi- -we expressed our opinion of a former edition ia 
tion the high standard of excellence which it had | terms of unqualified praise, and we are m no mood 
attained in previous editions, under the editorship of i j^, detract from that opinion in reference to the pre- 
its accomplished author. This has not been accoui- ggnt edition, the preparation of which has fallen into 
plished without much labor, and many additions and competent hands. It is a book with which no pharma- 
improvements, involving changes in the arrangement | pj^t can dispense, and from which no physician can 
of the several parts of the work, and the addition of j f^;] jg derive much information of value to him ia 
much new matter. With the modifications thus ef- . practice.— Paci/c Med. and Surg. Journ., June, '74. 
fected it constitutes, as now presented, a compendiuir 
of the science and art indis-pensable to the pharma 



cist, and of the utmost value to every practit 
of medicine desirous of familiarizing himself with 
the pharmaceutical preparation of the articles which 
he prescribes for his patients.— O^iieas'o Med. Jonrn., 
July, 1S74. 

The work is eminently prartical, and has the rare 
merit of being readable and interesting, while it pre- 
serves a stricMy scientific character. The whole work | gu 
reflects the greatest credit on author, editor, and pub- 
lisher It will convey some idea ofihe liberality which 
has been bestowed upon its production when we men- 
tion that there are no less than 280 carefully executed 
illustrations. In conclusion, we heartily recommend 
the work, not only to pharmacists, but also to the 
multitude of medical practitioners who are obliged 
to compound their own medicines. It will ever hoia 



With these few remarks we heartily commend the 
work, and have no doubt that it will maintain its 
old reputation as a textbook for the student, and a 
work of reference for the more experienced physi- 
cian and pharmacist.— CTueosfO Me&. Examiner, 
June lo, 1874. 

Perhaps one, if not the most important book npoB 
pharmacy which has appeared in the English lan- 



...„„ has emanated from the transatlantic press. 

Parrish's Pharmacy" is a well-known work on this 
side of the water, and the fact shows us that a really 
useful work never becomes merely local in its fame. 
Thanks to the judicious editing of Mr.Wiegand, th« 
posthumous edition of "Par 
the public ■ ' ' 



has been saved to 
ill the mature experience of its au- 



thor, and perhaps none the worse for a da.«h of new 
blood.— Xond. Pharm. Journal, Oct. 17, 1S74. 



CfTILLE (ALFRED), M.D., 

iO Professor of Theory and Practice of Medicine in the Vnittesrsity of Pe:^na. 

THERAPEUTICS AND MATERIA MEDIGA; a Systematic Treatise 

on the Action and Uses of Medicinal Agents, including their Description and HistorS- 
Fourth edition, revised and enlarged. In two large and handsome 8vo. vols, of aboat idm 
pages. Cloth, $10; leather, $12. {Just Issued.) 
The care bestowed by the author on the revision of this edition has kept the work ont of ths 
market for nearly two years, and has increased its size about two hundred and fifty pages 
withstanding this enlargement, the price has been kept at the former very moderate rate 
It is unnecessary to do much more than to an-; of the pres. ■■ ■ • ' =-- 



NoV 



nounce the appearance of the fourth edition of this 
well known and excellent work.— .BHi. and For. 
Med.-Chir. Review, Oct. 1875. 

For all who desire a complete work on therapeutics 
and materia medica for reference, in cases involving 
medico-legal questions, as well as for information 
concerning remedial agents. Dr. Still6's i.s "par ex- 
cellence" the work. The work being out of print, by 
the exhaustion of former editions, the author has laid 
the profession under renewed obligations, by the 
careful revision, important additions, and timely re- 
issuing a work not exactly supplemented by any 
other in the English language, if in any language. 
The mechanical execution handsomely sustains the 
well-known skill and good taste of the publisher.— 
Si. Louis Med. and Surg. Journal, Dec. 1874. 

The prominent feature of Dr. Still6's great work 
is sound good sense. It is learned, but its learning 
is of inferior value compared with the discriminating 
judgment which is shown by its author in the dis- 
cussion of his subjects, and which renders it a trust- 
worthy guide in the sick-room.— vim. Practitioner, 
Jan. 187.3. 

From the publication of the first edition " Still^'s 
Therapeutics" has been one of the classics; its ab- 
sence from our libraries would create a vacuum 
which could be filled by no other work in the lan- 
guage, and its presence supplies, in the two volumes 



ion, a whole cyclopaedia of thera- 
peutics.— C%i<?apo Medical Journal, ¥eh. 1875. 

The magnificent work of Pr&fessor Stille is known 
wherever the English language is read, and the art 
of medicine cultivated ; known so well that no enco- 
mium of ours could brighten its fame, and no unfa- 
vorable criticism could tarnish its reputation. -PWi- 
adelphia Med. Times, Dec. 12, 1874. 

The rapid exhaustion of three editions and the uni- 
versal favor with which the work has been received 
by the medical profession, are sufficient proof of its 
excellence as a repertory of practical and useful in- 
formation for the phy.sician. The edition before us 
fully sustains this verdict, as the work has been care- 
fully revised and in some portions rewritten, briug- 
ing it up to the present time by the admission of 
chloral and crotonchloral. nitrite of arayl, bichlo- 
ride of methylene, met hylic ether, lithium com- 
pounds, gelseminnm, and other remedies.— ^m. 
Journ. of Pharmacy, Feb. 1875. 

We can hardly admit that it has a rival in the 
multitude of its citations and the fulness of its re- 
search into clinical histories, and we must assign it 
a place in the physician's library; not, indeed, as 
fully representing the present state of knowledge iu 
pharmacodynamics, but as by far the most complete 
treatise upon the clinical and practical side of th» 
question —Bosio« Mtd. and. Surg. Journal, Hov.a, 
1874. 



Q 



Henry C. Lea's Publications — {Mat. Med. and Therapeutics). 13 

RIFFITH [ROBERT E.), M.D. 

A UNIVERSAL FORMULARY, Containingthe Methods of Prepar- 
ing and Administering Officinal and other Medicines. The wliole adapted to Physician! and 
Pharmaceutists. Third edition, thoroughly revised, with numerous additions, b^ John M. 
Maisch, Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large 
andhandsome octavo volume of about 800 pages, eloth, $4 50 ; leather, $5 50. (Just Issued.) 

This work has long been known for the vast amount of information which it presents in a con- 
densed form, arranged for easy reference. The new edition hag received the most careful revi- 
sion at the competent hands of Professor Maisch, who has brought the whole up to the standard of 
the most recent authorities. More than eighty new headings of remedies have been introduced, 
fche entire work has been thoroughly rentode'iled, and whatever has seemed to be obsolete has been 
omitted. As a comparative view of the United States, the British, the German, and the French 
Pharmacopceias, together with an immense amount of unofficinal formulas, it affords to the prac- 
titioner and pharmaceutist an aid in their daily avocations not to be found elsewhere, while three 
indexes, one of "Diseases and their Remedies," one of Pharmaceutical Names, and a General 
Indez, afford an easy key to the alphabetical arrangement adopted in the test. 



The young praetitioner will find the work invalu- 
able in suggesdng eligible modes of administering 
Eiany remedies. — Am. Joum. of Pkarm., Feb. 1874. 

Oar copy of GrifSth's Formulary, after long use, 
first in the dispensing siiop, and afterwards in oar 
medical practice, had gradually fallen behind in the 
onward march of materia medica, pharnjaey, and 
therapeutics, cntil we had ceased to consult it as s, 
daily book of reference. So completely has Prof. 
Maisch reformed, remodelled, and rejuvenated it iE 
the new edition, we shall gladly welcome it back to 
ourtable again beside Diinglisoii, Webster, and Wood 
& Bache. The publisher eonld not have been more 
forttinate in the selection of an editor. Prof. Maisch 
is eminently the man for the work, and he has done 
it thoroughly and ably. To enumerate the altera- 
tions, amendments, and additions would be an end- 
less task ; everywhere we are greeted with the evi- 
dences of his labor. Following the Formulary, is an 
addendum of useful Eecipes, Dietetic Preparations, 
List of incompatibles, Posological table, table of 
Pharmaceutical Names, Officinal Preparations and 
Directions, Poisons. Antidotes, and Treatment, and 
copious indices, which afford ready access to all parts 
«f the work. We unhesitatingly commend the book 
as being the best of its kind, within our knowledge. 
— Atlanta Med. and Hu-rg. Jourzi.., Feb. 1874. 



To the druggist a good formulary is simply indis- 
pensable, and perhaps no formulary has been more 
extensively used than the well-known work before 
us. Many physicians have to officiate, also, as drug- 
gists. This is true especially of the country physi- 
cian, and a work which shall teach him the means 
by which to administer or combine his remedies in 
the most efEcacion's and pleasant manner, will al- 
ways hold its place upon his shelf. A formulary of 
this kind is of benefit also to the city physician in 
largest practice.— Ci'/E.ci»?iafi Olinie, Feb. 21, 187-1. 

The Formulary has already proved itself accepta- 
ble to the medical profession, and we do not hesitate 
to say that the third edition is much improved, and 
of greater practical value, in consequence of the care- 
ful" revision of Prof Msbiseh.—Ohieago Med. Exam- 
iner, March 15, 1874. 

A more complete formulary than it is in its pres- 
ent form the pharmacist or physician could hardly 
desire. To the first some sueli work is indispensa' 
ble, and it is hardly less essential to the practitionei 
who compounds his own medicines. Much of what 
is contained in the introduction ought to be com 
mitted to memory by every student of medicine 
As a help to physicians it will be found invaluable 
and doubtless will make its way into libraries not 
already supplied with a standard work of the kind, 
~Tke American Fractiiioner, LouisviUe, July, '74, 



PLLIS {BENJAMIN), M.D. 

THE MEDICAL FORMULARY: being a Collection of Prescriptions 

derived from the writings and practice of many of the most eminent physicians of America 
and Europe. Together with the usual Dietetic Preparations and Antidotes for Poisons. The 
whole accompanied with a few brief Pharmaceutic and Medical Observations. Twelfth edi- 
tion, carefully revised and much improved by Albert H. Smith, M.D. In oaevolumeSv®. 
Qi 376 pages, cloth, $3 00. 



iEREIRA [JONATHAN), M.D., F.R.S. and L.S. 

MATERIA MEDICA AND THERAPEUTICS; being an Abridg- 
ment of the late Dr. Pereira's Elements of Materia Medica, arranged in conformity with 
the British Pharmacopoeia, and adapted to the use of Medical Practitioners, Chemists and 
Druggists, Medical and Pharmaceutical Students, &c. By E. J. Pabre, M.D. , Senior 
Physician to St. Bartholomew's Hospital, and London Editor of the British Pharmacopoeia ; 
assisted by RoBKhT Bhntley, M.R.C.S., Professor of Materia Medica and Botany to the 
Pharmaceutical Society of Great Britain; and by Robert Warington, F.R.S. , Chemical 
Operator to the Society of Apothecaries. With numerous additions and references to the 
United States Pharmacopoeia, by Horatio C. Wood, M.D., Professor of Botany in the 
University of Pennsylvania. In one large and handsome octavo volume of 1040 closely 
printed pages, with 236 illustrations, cloth, $7 00; leather, raised bands, $8 GO. 



D-nUGLISON'S NEW REMEDIES, WITH FORMUL.«: 
FOR THEIR PREPARATION AND ADMINISTRA- 
TION. Seventh edition, with extensive additions. 
One vol. Svo., pp. 770 ; cloth. $4 00. 

WHAT TO OBSERVE AT THE BEDSIDE AND AFTER 
Death in Medical Cares. Published under the 
authority of the London Society for Medical Obser- 
\ration. From the second London edition. 1 vol. 
eojral 12mo., cloth, *1 00, 



IHRISTISON'S DISPENSATORY. With copious ad 
■'U.lnnB, and 2ia larg** wooH-eneravinKB Bv R 
EaLESPELD Griffith, M.D. One vol. 8vo., pp. 1000 
cloth. *4 00. 
CARPENTER'S PRIZE ESSAY ON THE USE OF 
Alcoholic LiQnnRs in Hualth and Disrare. New 
edition, with a Preface by D. F. Condie, M.D., and 
explanations of scientific words. In one neat 12mo. 
volume, pp. 17S, cloth. 60 cents. 



14 



Henky C. Lea's Publications — {Pathology, So.). 



£ 



RONTON (T. LA UDER). M.D.. 

Lecturer on Materia Mertieri and Theropeitiins at St. Bartholomnc^x Snspitnl, &n. 

A MANUAL OF MATERIA :\IEDICA AND THERAPEUTICS. 

INCLUDING THE PHARMACY, THE PHYSIOLOGICAL ACTION, AND THE THE- 
RAPEUTICAL USES OF DRUGS. In one neat octavo volume. i,Pre},arutg.) 



PENWICK {SAMUEL), M.D., 

-*- Assistant I^hi/xicifin to the Londrm Hnapital. 

THE STUDENT'S GUIDE TO MEDICAL DIAGNOSIS. From the 

Third Revised and Enlarged English EditioD. With eigbty-four illustrations on wood- 
In one very handsome volume, royal 12mo., cloth, $2 26. {Jttst Issued.) 

Of the many guidfi-books on medical disgnosis, 
elaimed to be written for tlie g-pecial instruction of 
students, this is the best. The author is evidently a 
Trellvead and accoraplished physician, and he knows 
how to 'each practical medicine. Thecharra of sim- 
plicity is not the leastintTestJngfeatnrein the man- 
nerin which Dr. Fenwickconveys iiistrnction. There 
are few hooks of this size on practical medicine that 
contain so ninch and convey it so well as the volume 
before us. It is a book we can sincerely recommend 
10 the student for direct instrnction, and to the prac- 
titioner as a ready and usefnl aid to his memory.— 
Am. Journ. of Syphitograpky, Jan. 1874. 

It covers the ground ©f medical djagnosis in a con- 



cise, practical manner, well calculated to assist the 
stndei>t in forming a correct, thorong-h, and system- 
atic method of examination and diagnosis of disesbse. 
The illustrations are numerous-, acd finely executed. 
Those inustrative of the microscopic appearance of 
morbid tissue, &e., are esp-ecially cJesr and distinct. 
— Ohicago Med. Examiner, Nov. If 7.^ 

So far superior to any offered to students tiat the 
colleges of this coantry should recommend it to tbeir 
respective classes. — N. 0. Med. «-»<} Surg. Journ., 
March, 1874. 

This little book ougijt to be in the possession oJ 
every medical student.— ^oefo-n Medical aniSv^g. 
Journ., Jan. 15, 3ST-3. 



G 



RE EN {T. HENRY], M.D., 

Lrclurer 9n Pathology ami Mordid Anatomy ai Chariny-Cfross BosjyitaT Medicul School. 

PATHOLOGY AND MORBID ANATOMY. With BHrnerous Illus. 

trations on Wood. In ona very handsome octavo volume of over 350 pages, elotii, $2 50. 
{Lately Published.) 



We have been very much pleased by our perusal of 
Ibis little volume. It is the only one of the kind with 
which wo are acquainted, and practitioners as we!) 
as students will find it a very useful guide; for the 
lEformation is up to the da,y, well and compactly ar- 
ranged, without being at all sc&ryij.— London Lan- 
set, Oct. 7, 1871. 

It embodies in a compai-atively small space a clear 
statement of the present state of o-ur knowledge of pa- 



tboliogy and morbid snutomy. The authorsboTTS thai 
be has been not only a stHdent of the teachings of hi8 
eonfrires in this branch of science, but a practicaJ 
and eoascientious laborer in the post-mortem cham- 
ber. The worJi will provea useful one to the great 
mass of students and practitioners whose time for cl*(- 
votjon to this class of studies is Wmitei. — Am. Jwarn.. 
of Spphiletgraphp, April, 3S72. 



GLUG.B'S ATLAS 0? PATHOLOGICAL HISTOLOGY. 
Translated, with Kotes aud Additions, by Joseph 
Lkidt, M. D. In one volume, very large imperial 
quarto, with 320 copper-plate figures, plain and 
colored, cloth. $4 00. 

LA ROCHE ON YELLOW FEVER, considered in its 
Historical, Pathological, Etiological, and Therapeu- 
tical Relations. In two large and bs-ndsome oetav< 
volumes of nearly 1500 pages, clotii. $1 00. 

HOLLAND'S MEDICAL NOTES AND BEyLEC- 
Tioss. 1 vol. 8vQ., pp. 600, elotis. ^ 60. 



LAYCOCK'S LECTURES Olf THB PBIKCIPLE8 
AND Mbthods op Mbbjcax Obsbrvatios asb Kb- 
snAscH. For the use of advanced stiid&iitB and 
junior practitioners. la one very ne>at royal 12mr. 
voiniae, cloth. $1 00. 

BARLOW'S MANUAL 0? THE PRACTICE OT 
MEDICINE. With Additions by D. F. Cokbjb, 
M D I vol. 8vo., pp. 600, cloth. «;2 50. 

TODD'S CLINICAL LECTURES ON CERTAIN ACUTB 
Diseases. In one aeat octavo volume, of 320 paeea, 
cloth. ^ 50. 



s 



TVRGES (OCTAVIUS), M.D. Cantab., 

Fellow of the Royal College of Physicians, &c. &i. 

AN INTRODUCTION TO THE STUDY OF CLINICAL MED- 
ICINE. Being a Guide to the Investigation of Disease, for the Use of Stadeats. la one 
handsome 12ino. volume, cloth, $1 2&. {Latehj Ismed.^ 



'jTkA VIS [NA THAN S.), 

-^-^ Praf. of Principles and Pradtoc of Medicine, ete., in OMcags Mf.d. Gonegn. 

CLINICAL LECTURES ON VARIOUS IMPORTANT DISEASES ; 

being a colieotion of the Clinical Lectures delivered in the Medical Wards of Mercy H©s.. 
pital, Chicago. Edited by Frank H. Davis, M.D. Second edition, enlarged. In one 
handsome royall2mo. volume. Cloth, $1 75. {Lately I&sued.) 



CfTOKES (WILLIAM), M.D., D.G.L., F.R.S., 

^ Regius Professor of Physic in the Univ. of Dublin, *«. 

LECTURES ON FEVER, delivered in the Theatre of the Meath Hos- 

pital and County of Dublin Infirmary. Edited by John William Moore, M.D , Assistant 
Phy.sioian to the Cork Street Fever Hospital. In one neat octavo volume. (Preparing.) 
^*jlf To appear in the "Medical News anj) Libraky" for 1875. 



He^ey C. Lea's PuisLiGATiosf B-~(Prac^"ce of Medicine). 



15 



J^LINT {AUSTIN), M.D., 

•*■ Proff^sor of the Principl&s and Pra^stice of Hfedicine in Belle'oue Med. College, N. Y 

A TREATISE ON" THE PRINCIPLES AND PRACTICE OF 

MEDICINE ; designed for the use of Students and Practitioners of Medicine. Fonrtk 

edition, revised and enlarged. In one large and closely printed octavo volume of about 1100 

pages ; cloth, $6 GO ; or strongly bound in leather, with raised bands, $7 00. iJnst Issued.) 

Bj eommon consent of the English and American medical press, this work has been assigned 

to the highest position as a complete and compendious test-book on the most advanced conditioH 

of medical science. At the very moderate price at which it is offered it will be found one of the 

cheapest volumes now before the profession. A few notices of previous editions are subjoined. 

Admirable and unequalled. — Western Journal of \ sxceliently printed and bound — and we encounter 
Me/iicine, Nott. J859. that luxury of America, the ready-cut pages, whict 

Dr. Flint's vrork, though olasming no higher title the Yankees are 'cute enough fro insist upon — nor are 
than thatof a test-book, is really more. He is a man these by any means trifles ; but the contents of the 
of large clinical experience, and his book is full of ) t>oofe are astonishing. Not only is it wonderful that 
such masterly descriptions of -disease as can only be 1 1U7 oue man can h.=i.ve gra.spe<i in his mind the whole 
drawn by a man intimately acquainted with their j scope of medicine with th.at vigor which Dr. Flint 
variotF.s forms. It is not S'O loag sinee we had the ] 'bows, but the condensed yet clear way in which 
p/leasKre of reviewing his first edition, and we recog- i this is done is a perfect literary triumph. Dr. Flint 
ttize a great improvement, especially ia the general | ts pre-eminently one of the strong men, whose right 
part of the work. It is a work which we can cordially | to do this kind of thing is well admitted ; and we say 
frecommeud to our readers as fulJy abreast of the sci- j '^o more tha.E the ti-uth wheo we affirm that he is 



esQoe of the dLa,j.—Edinbu.rffk 3Ic.d. Journal, Oct. '69. 

One of the bast works of the kind for tfaa praetl- 
iveaieat of all for the studoat. 
?, Jaa. 1S69. 

This wort, which stands pre-eminently as the ad- 
vance standard of medical science up to tke present 
time iu tke practice of medicine, has for its author 
Otte who is well an-d wid*ly known as one <if th<3 
leading practitioners of this continent. In fact, it is 
seldom that any work is ever issued frosa the press 
iiiore d-sserving of universal recommendatioa. — Do- 
minion Med JourwMl, May, 1869. 

The third e-dUton of this most eEC«lleat book scarce- 
ly needs any comoiendation from ua. The volume, 
a.s it stands now, is really a marvel : first of aii, it is 



7ory nearly the oaly living man th&,t could do it with 
juch results as the volume before us. — The London 
PractitioTt&~, Mareh, 1869. 

This is itt some respects ihe best text-book of medi- 
cine in onr language, and it is highly appreciated oq 
the other side of the Atlantic, inasmuch as the firsi 
adition was exhausted in a few mouths. The secon<J 
edition was little more than a reprint, but the presenj 
h.a,s, as fiie author says, been thoroughly revised. 
Much valuable matter has been added, and by mak- 
ing the type smaller, the bulk of the volume' is not 
much increased. The weak point in many Americao. 
works is pathology, but Dr. Flint has taken peculiar 
pains on this point, greatly to the value of the book. 
—IjOvAon Med. Timee and Gazett'S, Feb. 6, 1860. 



13 F THE SAME AUTHOR. 

ESSAYS O^ CONSERVATTYE MEDICINE AND KINDRED 

TOPICS. In one very handsome royal 12mo. volume. Cloth, $i 3S. {Just Issued.') 

I. Ccaservative Medicine. II. Conservative Medicine as ipplied to Therapeutics. IIL Cok- 
gervative Medicine as applied to Hygiene. IV. Medicine in the Past, the Present, and the Fu- 
ture. Y. Alimeutition in Disease. VI. Tolerance of Disease. VII. On the Agency of the 
Sliad in Etiology, Pvophylaxis, 8.nd. Therapeutics. VIII. Diviae design as exemplified in the 
Natural Hisfcojy of Disease. 

l/fpi TSON {THOMAS), M. D., ^c. 

LECTURES ON THE PRINCIPLES AND PRACTICE OF 

PHYSIC. Delivered at King's College, London. A new American, from the Fifth re- 
vised and enlarged English edition. Edited, with additions, and several hundred illustra- 
atioEB, by Henry Hartshorste, M.B., Professor of Hygiene in the University of Pennsylv- 
nia. Ik two large and handsome 8to. vols. Cloth, $9 00 ; leather, $11 GO. [Lately Published.) 



ft is a subject for congratulation and for thankfu!- 
aess that Sir Thomas Watsou, daring a period of com- 
piratii^e leisure, after a, l<!ing, laborious, aad most 
laonorable psrofeesional career, while retaining full 
possession of his bigh mental faculties, should have 
employed the opportunity to submit his Lectures to 
a mor« thorough revision thivn was possible during 
the earlier and bnsier period of hSs life. Carefuiiy 
paseiagin reriew some of the most iatricate and im- 
portant pathological aad practical questions, there- 
suits of lii.ielear insight and his calm judgment are 
now recorded for the benefit of maEkind, in laugnago 
'^vbich, forpreci.iloa, vigor, and clasfticalelogan(;6. has 
rarely beeu e<iuaUed, and aever Burpasned The re- 
vision Ua« evidently been tao^t carefully done, and 
thereealts apf.earin almool every page. — JBrtt. Me.d. 
Journ., Oct. 14, 1871. 

The l^clares are so weil kuown and so Jastly 
appreciated, tViat St is «carc«ly nece.'fHary to do 
onor« thaa eall attention to the special advantages 
<rf th« last o<rer previo«« cditiGtts. Th« aiuhor'ii 



rare combination of great scientific attainments com- 
bined with wonderful forensic eloquence has exerted 
extraordioarj influence over the last two generations 
of phy.sicians. His clinical descriptions of most dis- 
eases have never been equalled ; and on this score 
at least his work will live long in the future. The 
work will be sought by all who appreciate a great 
book. — Arner. Journ. of Syphil-ography, July, 1872. 
We are exceedingly gratified at the reception of 
this new edition of Watson, pre-eminently the prince 
of English authors, on ■"Practice." We, who read 
the first edition shall never forgot the great pleasure 
and profit we derived from its graphic delineations 
of disease, its vigorous style aiid splendid English. 
M«turity of years, extensive observation, profound 
reKearch, and yet continuous enthusiasm, have com- 
bined to give us in this latest edition a model of pro- 
fessional ercellonco in tBaching with rare beauty in 
the mode of communication. But this classic needs 
no enloglum of ours. — Cliicago Med. Journ., July, 
1872. 



J^UNGLISON, FORBES, TWEED IE, AND CONOLLY. 

"^THE CYCLOPEDIA OF PRACTICAL MEDICINE: comprising 

Treatises on the Nature and Treatment of Diseases, Materia Medica and Therapeutics, 
Disetwes of Women and Children, Medical Jurisprudence, <tc. &c. In four large super-royal 
ftetftvo volumes, of 3254doaIile-eoIuuiaed pages, strflDgiy and handsomeiy bound ia leather, 
$15; doth, $11. 



16 Heney C. Lea's Publications — {Practice of Medicine). 

ffARTSHORNE [HENRY), M.D., 

-*-* Professor of Hygiene in the University of Pennsylvania. 

ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDI- 

CINE. A handy-book for Students and Practitioners. Fourth edition, revised and im- 
proved. V/ith about one hundred illustrations. In one handsome royal 12mo volume, 
of .-ibout 550 pages, cloth, $2 6.3; half bound, $2 88. {Just Issi/ecl.) 
The thorough manner in which the author has labored to fully represent in this favorite hand- 
book the most advanced condition of practical medicine is shown by the fact that the present 
edition contains more than 250 additions, representing the investigations of 172 authors not re- 
ferred to in previous editions. Notwithstanding an enlargement of the pnge, the siie has been 
increased by sixty pages. A number of illustrations have been introduced which it is hoped 
will facilitate the comprehension of details by the reader, and no effort has been spared to make 
the volume worthy a continuance of the very great favor with which it has hitherto been received. 
The work is brought folly up with all the recent | Without doubt the best book of the kind published 
advances in medicine, is admirably condensed, and | in the Eujili^h language.— 5<. ioMi> Mud and Sura. 
yet sufficiently explicit for all the purposes intended, j Jonrn., Mot. IS7-i. 

thus making it by far the best work of its character 4„„v.„ju , vv ^ , » , .i. »». 
ever pnblished.-Cmcinnati Clinic, Oct. 24, 1S7-4. .,,ff * ^f,«^'''">olf- ^^'<'^ clearly sets forth tbeEssuw- 

' ' I TIAJ.SOf thei>Rl.NCIPI.ESA.ND?RACTI0BOFMEDieiUE, we 

We have already had occasion to notice the previ- [ ^'^ ^^^ know of its equal.— Fo. Med. Monthly. 
ous editions of this work. It is excellent of its kind. I As a brief, condensed, but comprehensive hand- 
The author has given a very careful revision, in view I book, it cannot be improved upon —Ohieago Med 
of the rapid progress of medical science.— iV. Y. Med. Examiner, ISov. 35, 1&74. 
Journ., Not. 1S74. 



pAVY [F. W.), M. D., F. R. S., 

JL Senior Asst. Physician to and Lecturer on Physio logy, at Guy's Eo»pUal, Ac. 

A TREATISE ON THE FUNCTION OF DIGESTION; its Disor- 
ders and their Treatment. From the second London edition. In one handsome volume, 
small octavo, cloth, $2 00. 
■DY THE SAME AUTHOR. (Just Is-nted.) 

A TREATISE ON FOOD AND DIETETICS, PHYSIOLOGI- 
CALLY AND THERAPEUTICALLY CONSIDERED. In one handsome octavo volame 
of nearly 609 pages, cloth, $4 75. 

SnMMAKY OF CONTENTS. 

Introductory Remarks on the Dynamic Relations of Food— On the Origination of Food— The 
Constituent Relations of Food— Alimentary Principles, their Classification, Chemical Relati ons. 
Digestion, Assimilation, and Physiological Uses— Nitrogenous Aliujentary Principles— Non- Ni- 
trogenous Alimentary Principles— The Carbo- Hydrates— The Inorganic Alimentary Principles- 
Alimentary Substances — Animal Alimentary Substances — Vegetable Alimentary Substances 

Beverages— Condiments— The Preservation of Food— Principles of Dietetics— Practical Dietetics 
—Diet of Infants— Diet for Training— Therapeutic Dietetics— Dietetic Preparations for the Inva- 
lid — Hospital Dietaries. 

pUAMBERS [T. K.), M.D., 

^ Consulting Physician to Si. Mary's Hospital, London, &e. 

A MANUAL OF DIET AND REGIMEN IN HEALTH AND SICK- 
NESS. In one handsome octavo volume. Cloth, $2 75. {Now Ready.) 

convey his meaning ia the fewest possible words, he 
is certainly unexcelled and rarely equalled by any 
writer in the English language. It is altogether a 
work of rare excellence, and should, as it doubtless 
will, speedily find a place on the table of every phy- 
sician.— 37je if. Y. Sanitarian, June, 1875. 

This work is a substantial addition to our standard 
works, and not only should tht neat little volume 
find a place in the most restricted libraries, but its 
contents ought to be read, marked, learned, and in- 
wardly digested by each practitioner, until they 
have become woven into the web of the ordinary 
every-day thought of all medical men who truly love 
their profession.— iond. Practitioner, June, 1375. 



In eompilingthis small but eomprehensire maaual 
Dr. Chambers has laid the profession under a debt 
of gratitude to him. Rewrites on the subject like 
one who has given his mind to it, and therefore is 
entitled to speak with authority. As a pioneer, Dr. 
Chambers deserves much credit ; he has opened up a 
new field of which others will no doubt avail them- 
selves. Taken altogether, this work is one which 
gives, in an agreeable form, much valuable informa- 
tion on a most important subject, and ought to have 
a large sale both in the profe.ssion and out of it. — 
London Med. Record, May If), 1875. 

In thorough mastery of the subjects upon which he 
writes, and in the happy command of language to 



J^Y THE SAME AUTHOR. (Lately Published.) 

RESTORATIVE MEDICINE. An Harveian Annual Oration. With 

Two Sequels. In one very handsome volume, small 12mo., cloth, $1 00. 
JDRINTON [WILLIAM), M.D., F.R^S. 

LECTURES ON THE DISEASES OF THE STOMACH; with an 

Introduction on its Anatomy and Physiology. From the second and enlarged London edi. 
tion. With illustrations on wood In one handsome octavo volume of about 300 Daeea 
cloth, $3 25. *^ * 

pox ( WILSON), M.D., 

-*■ Holme Prof, of CHjiical Med., University Coll., London. 

THE DISEASES OF THE STOMACH: Being the Third Edition of 

the "Diagnosis and Treatment of the Varieties of Dyspepsia." Revised and Enlarged. 
With illustrations. In one handsome octavo volume, cloth, $2 00. (Just Issued.) 



Henry C. Lea's Publications. 



17 



J^LINT {AUSTIN), M.D., 

-»■ Professor of the Principles and Practice of Medicine in Bellevue Hospital Med. College, IT. T. 

A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, 

AND TREATMENT OF DISEASES OF THE HEART. Second revised and enlarged 
edition. In one octavo volume of 550 pages, with a plate, cloth, $4. 



Dr. Tlint chose a difficult subject for his researches, 
and has shown remarkable powers of observation 
and reflection, as well as great industry, in his treat- 
ment of it. His book must be considered the fullest 
and clearest practical treatise on those subjects, and 
should be in the hands of all practitioners and stu- 
dents. It is a credit to American medical literature. 
—Amer. Journ. of the Med. Sciences, July, 1860. 

We question the fact of any recent American author 
in our profession being more extensively known, or 
more deservedly esteemed in this country than Dr. 
Flint. We willingly acknowledge his success, more 
Tjartlcnlarly in the volume on diseases of the heart, 
in making an extended personal clinical study avail- 



able for purposes of illustration, in connection with 
cases which have been reported by other trustworthy 
observers. — Brit. a7id For. Med.-Chirurg. Review. 

In regard to the merits of the work, we have no 
hesitation in pronouncing it full, accurate, and judi- 
cious. Considering the present state of science, such 
a work was much needed. It should be in the hands 
of every practitioner. — Chicago Med. Joxtrn. 

With more than pleasure do we hail the advent of 
this work, for it fills a wide gap on the list of text- 
books for our schools, and is, for the practitioner, the 
most valuable practical work of its kind. — N. 0. Med. 



or THE SAME AUTHOR. 

A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- 
TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE 
RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume 
of 595 pages, cloth, $4 50. 



Dr. Flint's treatise is one of the most trustworthy 
guides which we can consult. The style is clear and 
distinct, and is also concise, being free from that tend- 
ency to over-refinement and unnecessary minuteness 
which characterizes many works on the same sub- 
ject.— Z>!tJhn Medical Press, Feb. 6, 1867. 

The chapter on Phthisis is replete with interest ; 
and his remarks on the diagnosis, especially in the 
early stages, are remarkable for their acumen and 
great practical value. Dr. Flint's style is ciear and 
elegant, and the tone of freshness and originality 



which pervades his whole work lend an additional 
force to its thoroughly practical character, which 
cannot fail to obtain for it a place as a standard work 
on diseases of the respiratory system. — London 
Lancet, Jan. 19, 1867. 

This is an admirable book. Excellent in detail and 
execution, nothing better could be desired by the 
practitioner. Dr. Flint enriches his subject with 
much solid and not a little original observation.— 
Ranking'' s Abstract, Jan. 1867. 



DF THE SAME AUTHOR. {Jii,st Ready.) 

PHTHISIS: ITS MORBID ANATOMY, ETIOLOGY, SYMPTOM- 
ATIC EVENTS AND COMPLICATIONS, FATALITY AND PROGNOSIS, TREAT- 
MENT, AND PHYSICAL DIAGNOSIS ; in a series of Clinical Studies. By Austin 
Flint, M.D., Prof, of the Principles and Practice of Medicine in Bellevue Hospital Med. 
College, New York. In one handsome octavo volume. 

This volume, containing the results of the author's extended observation and experience on a 
subject of prime importance, cannot but have a claim upon the attention of every practitioner. 



fpVLLER [HENRY WILLIAM), M. D., 

■*■ Physicia,n to St. George's Hospital, London. 

ON DISEASES OF THE LUNGS AND AIR-PASSAGES. Their 

Pathology, Physical Diagnosis, Symptoms, and Treatment. From the second and revised 
English edition. In one handsome octavo volume of about 500 pages, cloth, $3 50. 



Vi/'ILLIAMS {C.J.B.), M.D., 

Senior Consulting Physician to the Hospital for Consumption, Brampton, and 

TUILLIAMS [CHARLES T.), M.D., 

Physician to the Hospital for Consumption. 

PULMONARY CONSUMPTION; Its Nature, Varieties, and Treat- 

ment. With an Analysis of One Thousand Cases to exemi^lify its duration. In one neat 
octavo volume of about 350 pages, cloth, $2 50. {Lately Published.) 



He can still speak from a more enormous experi- 
eace, and a closer study of the morbid processes in- 
volved iu tuberculosis, than most living meu. He 
owed it to himself, and to the importance of the sub- 
ject, to embody his views in a separate work, and 
we are glad that he has accomplished this duty. 



After all, the grand teaching which Dr Williams has 
for the profession is to bo found in his therapeutical 
chapters, and in the history of individual cases ex- 
tended, by dint of care, over ten, twenty, thirty, and 
9ven forty years.— i/o»irfon Lancet, Oct. 21, 1S71. 



LA ROCHE ON PNETTMONIA. 1 vol. 8vo., cloth. 

of 500 pages. Price $:< 0(1. 
SMITH ON CONSUMPTION; ITS EARLY ANDRE 

MEDIABLE STAGES. 1 vol. 8vo., pp. 284. $2 26. 



WALSHB ON THE DISEASES OF THE HEART AND 
GREAT VESSELS. Third American edition. la 
1 vol. Svo., ■120 pp., cloth. ijtS 00. 



18 



Henry C. Lea's Publications — {Practice of Medicine). 



ROBERTS ( WILLIAM), M. D.. 

*«^ Lecturer on Medicine in the 3Ianchester School of Medicine. &c. 

A PRACTICAL TREATISE ON URINARY AND RENAL DIS- 

EASES, including Urinary Deposits. Illustrated by numerous cases and engravinpjs. Sec- 
ond American, from the Second Revised and Enlarged London Edition. In one large 
and handsome octavo volume of 616 pages, with a colored plate ; cloth, $4 50. {Lately 
Published.) 
The author has subjected this work to a very thorough revision, and has sought to embody in 
it the results of the late.st experience and investigations. Although every effort has been made 
to keep it within the limits of its former size, it has been enlarged by a hundred pages, many 
new wood-cuts have been introduced, and also a colored plate representing the appearance of the 
different varieties of urine, while the price has been retained at the former very moderate rate. 
The plan, it will thus be seen, is very complete, | diseases we have examined. It is peculiarly adapted 
an 1 the manner in which it has been carried out is to the wants of the majority of American practltion- 
in the hiijhest degree satisfactory. The characters ers from its clearness and simple announcement of the 



of the different deposit.? are very well described, and 
the microscopic appearances they present are illus- 
trated by numerous well executed engravings. It 
only remains to ns to strongly recommend 



facts in relation to diagnosis and treatment of urinary 
disorders, and contains in condensed form the investi- 
gations of Bence Jones, Bird, Beale, Hassall, Front, 
and a host of other well-known writers upon this sub- 



readers Dr. Roberts's work, as coniaining an admira- I ject. The characters of urine, physiological and pa- 
ble rcsumt of the present state of knowledge of uri- | thological, as indicated to the naked eye as well as by 
nary diseases, and as a safe and reliable guide to the I microscopical and chemical investigations, are con- 
clinical observer. — Edin. Med. Jour. cisely represented both by description and by well 
The mostcompleteand practical treatise upon renal i executed engravinga.-CijicmnaiJi Jour-n. of Med. 



B 



ASH AM [W.R.), M.D., 

Senior Phy.iician to the Westmi7i.9ter Hospital, *c. 

RENAL DISEASES: a Clinical Guide to their Diagnosis and Treatment. 

With illustrations. In one neat royal 12mo. volume of 304 pages, cloth, $2 00. 



The chapters on diagnosis and treatment are very 
good, and the student and young practitioner will 
find them full of valuable practical hints. The third 
part, on the urine, is excellent, and we cordially 
recommend its perusal. The author has arranged 
his matter in a somewhat novel, and, we think, use- 
ful form. Here everything can be easily found, and, 
what is more important, easily read, for all the dry 



details of larger books here acquire a new interest 
from the author's arrangement. This part of the 
book is full of good work. — Brit, and For. MedicO' 
nhirurgical Review, July, 1870. 

The easy descriptions and compact modes of state- 
ment, render the book pleasing and convenient. — Am. 
Journ. Med. Sciences, July, 1S70. 



TTNCOLN [D. F.). 31. D., 

-*-' Physician to the Depi.rfment of Nervous Diseases, Boston Dispens^'ry. 

ELECTRO THERAPEUTICS ; 1 Concise Manual of Medical Electri- 

city. Inone very neat royal 12mo. volume, cloth, with illustrations, $1 60. (Just Issued.) 



The work is convenient in size, its descriptions of 
methods and appliances are sufficiently complete for 
the general practitioner, and the chapters on Electro- 
physiology and diagnosis are well written and read- 
able. For those who wish a handy-book of directions 
for the employment of galvanism in medicine, this 
will serve as a very good and reliable guide. — New 
Eemedies, Oct. 1874. 

It is a well written work, and calculated to meet 
the demands of the busy practitioner. It contains 
the latest researches in this important branch of med- 
icine. — Penin.'iular Journ. of Med., Oct. 1874. 

Eminently practical in character. It will amply 
repay any one for a careful perusal. — Leavenworth 
Med. Herald, Oct. 1874. 



This little book is, considering its size, one of the 
very best of the English treatises on its subject that 
has come to our notice, possessing, among others, the 
rare merit of dealing avowedly and actually with 
principles, mainly, rather than with practical details, 
thereby supplying a real want, instead of helping 
merely to flood the literary market. Dr. Lincoln's 
style is usually remarkably clear, and the whole 
book is readable and interesting, — Boston Med. and 
Surg. Journ., July 23, 1874. 

We have here in a small compass a great deal of 
valuable information upon the subject of Medical 
Electricity. — Canada Med. and Surg. Journ., Nov. 

1874. 



TEE [HENRY), 

Prof, of Surgery at the Royal College of Surgeons of England, etc. 

LECTURES ON SYPHILIS AND ON SOME FORMS OF LOCAL 

DISEASE AFFECTINa PRINCIPALLY THE ORGANS OP GENERATION. In one 
handsome octavo volume : cloth; $2 26. (Now Ready.) 
COKTTBKTTS. 

Lectures I., II., III. General. — IV. Treatment of Syphilis — V. Treatment of Particular 
and Modified Syphilitic Affections — VI. Second Stage of Lues Venerea; Treatment — VII. Lo- 
cal Suppurating Venereal iSore ; Syy>hilization ; Lymphatic Absorption ; Physiological Absorp- 
tion ; Twofold Inoculation — VIII. Urethral Discharges : different kinds; Treatment; Conclu- 
sions of Hunter and Ricord — IX. Prostatic Discharges — X. Lymphatic Absorption continued ; 
Local Affections ; Warts and Excrescences. 



DIPHTHERIA ; its Nature and Treat Toent, with an 
account of the History of its Prevalence in vari- 
ous Countries. By D. D. Slade, M.D. Second and 
revised edition. In one neat royal 12mo. volume, 
cloth, $1 2.5. 

LECTURES ON THE STUDY OF FEVER. By A. 
Hudson, M.D., M.R.I.A., Physician to the Meath 
Hospital. In one vol. Svo., cloth, $2 50. 



By Robert D. Lyons, 
ime of 362 pages, cloth. 



A TREATISE ON FEVER. 
K C C. In one octavo volu 
$2 25. 

CLINICAL OBSERVATIONS ON FUNCTIONAL 
NERVOUS DISORDERS By C. Handfield Jones, 
M.D., Physician to St. Mary's Hospital, &c. Sec- 
ond Ame'rican Edition. In one handsome octavo 
volume of .318 pages, cloth, $3 25. 



Henry C. Lea's Publications — ( Venereal Diseases^ etc.). 



19 



J>UMSTEAD {FREEMAN J.), M.D., 

J-' Professor of Veriereal Diseases at the Qol. of Phya. and Surg., New Tork, &c. 

THE PATHOLOGY AND TREATMENT OF YENEREAL DIS- 
EASES. Including the results of recent investigations upon the subject. Third edition, 
rerised and enlarged, with illustrations. In one large and handsome octavo volume of 
over 700 pages, cloth, $5 00 ; leather, $6 00. 
In preparing this standard work again for the pjess, the author has subjected it to a very 
thorough revision. Many portions have been rewritten, and much new matter added, in order to 
bring it completely on a level with the most advanced condition of syphilography, but by careful 
compression of the text of previous editions, the work has been increased by only sixty-four pages. 
The labor thus bestowed upon it, it is hoped, will insure for it a continuance of its position as a 
complete and trustworthy guide for the practitioner. 



It is tlie most complete book with which we are ac- 
quainted in the language. The latest views of the 
best authorities are put forward, and the information 
Is well arranged — a great point for the student, and 
still more for the practitioner. The subjects of vis- 
ceral syphilis, syphilitic affections of the eyes, and 
the treatment of syphilis by repeated inoculations, are 
very fully discussed. — London Lancet, Jan. 7, 1871. 

Dr. Bumstead's work is already so universally 
known as the best treatise in the English language on 
venereal diseases, that it may seem almost superflu- 
ous to say more of it than that a new edition has been 
Issued. But the author's industry has rendered this 
new edition virtually a new work, and so merits as 



pULLERIER [A.], and 

v^' Surgeon to the Hdpital du Midi. 



much special commendation as if its predecessors had 
not been published. As a thoroughly practical book 
on a class of diseases which form a large share of 
nearly every physician's practice, the volume before 
us is bv far the best of which we have knowledge. — 
N. r. Medical Gfazette, Jan. 28, 1871. 

It is rare in the history of medicine to find any one 
book which contains all that a practitioner needs to 
know; while the possessor of "Bumstead on Vene- 
real" has no occasion to look outside of its covers for 
anything practical connected with the diagnosis, his- 
tory, or treatment of these affections.— iV. Y. Medical 
Journal, March, 1871. 



J?UMSTEAD {FREEMAN J.), 

-'-' Professor of Venereal Diseases in the Oollegeof 
Physicians and Surgeons, N. T. 

AN ATLAS OF YENEREAL DISEASES. Translated and Edited by 

Freeman J. Bumstead. In one large imperial 4to. volume of 328 pages, double-columns, 
with 26 plates, containing about 150 figures, beautifully colored, many of them the size of 
life; strongly bound in cloth, $17 00 ; also, in five parts, stout wrappers for mailing, at $3 
per part. 
Anticipating a very large sale for this work, it is offered at the very low price of Three Dol- 
lars a Part, thus placing it within the reach of all who are interested in this department of prac- 
tice. Gentlemen desiring early impressions of the plates would do well to order it without delay. 
A specimen of the plates and text sent free by mail, on receipt of 25 cents. 
We wish for once that our province was not restrict- which for its kind is more necessary for them to have. 



ed to methods of treatment, that we might say some- 
thing of the exquisite colored plates in this volume. 
— London Practitioner, May, 1869. 

As a whole, it teaches all that can be taught by 
means of plates and print. — London Lancet, March 
13, 1869. 

Superior to anything of the kind ever before issued 
on this continent. — Canada. Med. Journal, March, '69. 

The practitioner who desires to understand this 
branch of medicine thoroughly should obtain this, 
the most complete and best work ever published. — 
Dorainion Med. Journal, May, 1869. 

This is a work of master hands on both sides. M. 
CuUerier is scarcely second to, we think we may truly 
say is a peer of the illustrious and venerable Ricord, 
while in this country we do not hesitate to say that 
Dr. Bumstead, as an authority, is without a rival. 
Assuring our readers that these illustrations tell the 
whole history of venereal disease, from its inception 
to its end, we do not know a single medical work, 



California Med. Gazette, March, 

The most splendidly illustrated work in the lan- 
guage, and in our opinion far more useful than the 
French original. — Am. Joiirn. Med. Sciences, Jan. '69. 

The fifth and concluding number of thi,s magnificent 
work has reached us, and we have no he.sitation in 
saying that its illustrations surpass those of previous 
numbers. — Boston Med. and Surg. Journal, Jan. 14, 
1869. 

Other writers besides M. CuUerier have given ns a 
good account of the diseases of which he treats, but 
no one has furnished us with such a complete series 
of illustrations of the venereal diseases. There is, 
however, an additional interest and value possessed 
by the volume before us ; for it is an American reprint 
and translation of M. Cullerier's work, with inci- 
dental remarks by one of the most eminent American 
syphilographers, Mr. Bumstead. — Brit, and For. 
Medico-Ohir. Remew, July, 1869. 



IP 



LL {BERKELEY), 

Surgeon to the Lock Hospital, London. 

ON SYPHILIS AND LOCAL 

one handsome octavo volume ; cloth, $3 
Bringing, as it does, the entire literature of the dis- 
ease down to the present day, and giving with great 
ability the results of modem research, it is in every 
respect a most desirable work, and one whicli should 
find a place iu the library of every surgeon. — Cali- 
fornia Med. Gazette, June, 1869. 

Considering the scope of the book and the careful 
attention to the manifold aspects and details of its 
subject, it is wonderfully concise All these qualities 
render it an especially valuable book to the beginner, 



In 



CONTAGIOUS DISORDERS. 

25. 

to whom we would most earnestly recommend lt» 
study ; while it is no less useful to the practitioner.— 
St. Louis Med. and Surg. Journal, May, 1869. 

The most convenient and ready book of reference 
we have met with. — N. T. Med. Record, May 1, 1869. 

Most admirably arranged for both student and prac- 
titioner, no other work on the subject equals it ; it 1» 
more simple, more easily studied. — Buff<ilo Med. and 
Surg. Journal, March, 1869. 



^EISSL {H.), M.D. 

A COMPLETE TREATISE ON YENEREAL DISEASES. Trans- 
lated from the Second Enlarged Qermnn Edition, by Frederic R. Sturgis, M.D In one 
octavo volume, with illustrations. (Preparing.) 



20 



Henry C. Lea's Publications — (Diseases of the Skin). 



T^ILSON [ERASM US), F. R. S. 

ON DISEASES OF THE SKIN. With Illustrations on wood. Sev- 
enth American, from the sixth and enlarged English edition. In one large octavo volume 
of over 800 pages, $5. 

A SERIES OF PLATES ILLUSTRATING "WILSON ON DIS- 
EASES OF THE SKIN; " consisting of twenty beautifully executed plates, of which thir- 
teen are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, 
and embracing accurate representations of about one hundred varieties of disease, most of 
them the size of nature. Price, in extra cloth, $5 60. 

Also, the Text and Plates, bound in one handsome volume. Cloth, $10. 



No one treating skiu diseases should be irithont 
a copy of this standard work. — Canada Lancet. 

We can safely recommend it to the profession a« 
the best work on the subject now in existence ir 
the English language. — Medical Times and Gazette 

Mr. Wilson's volume is an excellent digest of the 
actual aiiioant of knowledge of cutaneous diseases 
it includes almost every fact or opinion of importance 
connected with the anatomy and pathology of th« 
skin. — British and Foreign Medical Review. 

Such a work as the one before us is a most capital 
^T THE SAME AUTHOR. 

THE STUDENT'S BOOK OF CUTANEOUS MEDICINE and Dis- 

In one very handsome royal 12mo. volume. $3 50. 



ind acceptable help. Mr. Wilson has long been held 
is high authority in this department of medicine, and 
his book on diseases of the skin has long been re- 
garded as one of the best text-books extant on the 
subject. The present edition is carefully prepared, 
md brought up in its revision to the present time. In 
'his edition we have also included the beautiful series 
of plates illustrative of the text, and in the last edi- 
tion published separately. There are twenty of these 
plates, nearly all of them colored to nature, and ex- 
hibiting with great fidelity the various groups of 
Oinsinnati Lancet. 



5S OP THE SI 



T^ELIGAN {J.MOORE), M.D., M.R.I.A. 
'^ A PRACTICAL TREATISE ON DISEASES OF THE SKIN. 

Fifth American, from the second and enlarged Dublin edition by T. W. Belcher, M.D. 
In one neat royal 12mo. volume of 462 pages, cloth, $2 25. 



their value justly estimated ; in a word, the work is 
fully up to the times, and is thoroughly stocked with 
most valuable information. — New Tork Med. Record, 
Jan. 15, 1867. 

The most convenient manual of diseases of the 
skin that can be procured by the student. — Chicago 
Med. Jotirnal, Dec. 1866. 



Fully equal to all the requirements of students and 
young practitioners. — Duhlin Med. Press. 

Of the remainder of the work we have nothing be- 
yond unqualified commendation to offer. It is so far 
the most complete one of its size that has appeared, 
and for the student there can be none which can com- 
pare with it in practical value. All the late disco- 
veries in Dermatology have been duly noticed, and 
or THE SAME AUTHOR. 

ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto 

volume, with exquisitely colored plates, &c., presenting about one hundred varieties of 
disease. Cloth, $5 50. 
The diagnosis of eruptive disease, however, under I inclined to consider it a very superior work, corn- 
all circumstances, is very difficult. Nevertheless, | bining accurate verbal description with sound viewi 
Dr. Neligan has certainly, "as far as possible," given [ of the pathology and treatment of eruptive diseases, 
a faithful and accurate representation of this class of | — Gla.Sffow Med. Journal. 

diseases, and there can be no doubt that these plates A compend which will very much aid the practi- 
willbeofgreat use to the student and practitioner in tioner in this difficult branch of diagnosis. Taken 
drawing a diagnosis as to the class, order, and species | with the beautiful plates of the Atlas, which are re- 
to which the particular case may belong. While ma.rkable for their accuracy and beauty of coloring, 
looking over the "Atlas" we have been induced to it constitutes a very valuable addition to the library 
examine also the "Practical Treatise," and we are I of a practical mun.— Buffalo Med. Journal. 



fJILLIER {THOMAS), M.D., 

•'"'- Physician to the Skin Department of University College Hospital, &c. 

HAND-BOOK OF SKIN DISEASES, for Students and Practitioners. 

Second American Edition. In one royal 12mo. volume of 358 pp. With Illustrationa. 

Cloth, $2 25. 
We can conscientiously recommend it to the stu- It is a concise, plain, practical treatise on the vari- 
dent; the style is clear and pleasant to read, the 
matter is good, and the descriptions of disease, with 
the modes of treatment recommended, are frequently 
Ulustrated with well-recorded cases. — London Med. 
Times and Gazette, April 1, 1865. 



ous diseases of the skin ; just such a work, indeed, 
as was much needed, both by medical students and 
practitioners. — Chicago Medical Examiner, May, 
1865. 



ANDERSON {McCALL), M.D., 

-^^ Physician to the Dispensary for Skin Diseases, Glasgow, <fec. 

ON THE TREATMENT OF DISEASES OF THE SKIN. With an 

Analysisof Eleven Thousand Consecutive Cases. In one vol. 8vo. $1. (Lately Published.) 



OUERSANT'S SURQICAli DISEASES OF INFANTS 
AND CHILDREN. Translated by R. J. Dunqli- 
BON, M.D. 1 vol. 8vo. Cloth, $2 50. 



OEWEES ON THE PHYSICAL AND MEDICAL 
TREATMENT OF CHTT.ORRN Elsvonth edition. 
1 voi. i^TO. of fi-iS pages. Cloth, $2 80. 



Henry C. Lea's Fvibjaoations— (Diseases of Gkildren). 31 

fJMITR [J. LE WIS), M. D., 

1^ Professor of Iforbid Anatomy in the Bellevue Hospital Med. College, N. Y. 

A COMPLETE PRACTICAL TREATISE ON THE DISEASES OF 

CHILDREN. Third Edition, revised and enlarged. In one handsome octavt volume. 
{Preparing.) 

From the Preface to the Second Edition. 

In presenting to the profession the second edition of his work, the author gratefully acknow- 
ledges the favorable reception accorded to the first. He has endeavored to merit a continuance 
of this approbation by rendering the volume much more complete than before. Nearly twenty 
additional diseases have been treated of, among which may be named Diseases Incidental to 
Birth, Rachitis, Tuberculosis, Scrofula, Intermittent, Remittent, and Typhoid Fevers, Chorea, 
and the various forms of Paralysis. Many new formulas, which experience has shown to be 
useful, have been introduced, portions of the text of a less practical nature have been con- 
densed, and other portions, especially those relating to pathological histology, have been 
rewritten to correspond with recent discoveries. Every effort has been made, however, to avoid 
an undue enlargement of the volume, but, notwithstanding this, and an increase in the size of 
the page, the number of pages has been enlarged by more than one hundred. 

227 West 49th Street, New York, April, 1872. 

The work will be found to contain nearly one-third more matter than the previous edition, and 
it is confidently presented as in every respect worthy to be received as the standard American 
text-book on the subject. 

Eminently practical as well as judicious In its 
te-achings. — Cincinnati Lancet and 06*., July, 1S72. 

A standard work that leaves little to be desired. — 
Indiana Journal of Medicine, July, 1872. 

We know of no book on this subject that we can 
more cordially recommend to the medical student 
and thepractitioner. — Cincinnati Clinic, June 29, '72. 



We regard it as superior to any other single work 
on the diseases of infancy and childhood. — Detroit 
Rev. of Med. and Pharmacy, Aug. 1872. 

We confess to increased enthusiasm in recommend- 
ing this second edition. — St. Louis Med. and Surg. 
Journal, Aug. 1872. 



ffONDIE [D. FRANCIS), M.D. 
. PRACTICAL TREATISE 

Sixth edition, revised and augmented. In one large octavo volume of nearly 800 closely- 
printed pages, cloth, $5 25 ; leather, $6 25. 
The present edition, which is the sixth, is fully up I teachers. As a whole, however, the work is the best 
to the times in the discussion of all those points in the | American one that we have, and in its special adapta- 
pathology and treatment of infantile diseases which tion to American practitioners it certainly has' no 
have beenbroughtforwardbythe German and French j equal. — New York Med. Record, March 2, 1868. 



VirEST {CHARLES), M.D., 

' ^ Physician to the Hospital for Sick Children. &c. 

LECTURES ON THE DISEASES OF INFANCY AND CHILD^ 

HOOD. Fifth American from the sixth revised and enlarged English edition. In one large 
and handsome octavo volume of 678 pages. Cloth, $4 60 ; leather, $5 50. {Just Issued.) 
The continued demand for this work on both sides of the Atlantic, and its translation into Ger- 
man, French, Italian, Danish, Dutch, and Russian, show that it fills satisfactorily a want exten- 
sively felt by the profession. There is probably no man living who can speak with the authority 
derived from a more extended experience than Dr. West, and his work now presents the results of 
nearly 2000 recorded cases, and 600 post-mortem examinations selected from among nearly 40,000 
cases which have passed under his care. In the preparation of the present edition he has'omitted 
much that appeared of minor importance, in order to find room for the introduction of additional 
matter, and the volume, while thoroughly revised, is therefore not increased materially in size. 

Of all the English writers on the diseases of chil- lliving authorities in the difficult department of medl- 
dren, there is no one so entirely satisfactory to us as | oal science in which he is most widely known.— 
Dr. West. For years we have held his opinion as I Boston Med. and Surg. Journal. 
judicial, and have regarded him as one of the highest | 



^Y THE SAME AUTHOR. {Lately Issued.) 

ON SOME DISORDERS OF THE NERYOUS SYSTEM IN CHILD- 
HOOD; being the Lumleian Lectures delivered at the Royal College of Physicians of Lon- 
don, in March, 1871. In one volume, small 12mo., cloth, $1 00. 

gMITH [EUSTA CE), M. D., 

Physician to the Northwest London Frte Dispensary for Sick Children. 

A PRACTICAL THEATISE ON THE WASTING DISEASES OF 

INFANCY AND CHILDHOOD. Second American, from the second revised and enlarged 
English edition. In one handsome octavo volume, cloth, $2 50. {Lately Issued.) 
This is in every way an admirable book. Th< 

modest title which the author has chosen foritncarce 

lyconvey« an adequate idea of the many mbjectt 

upon which it treats. Wasting is so constant an at 



tendant upon the maladies of childhood, that a t 
tise upon the wasting diseases of children must neces 
tarily embrace the consideration of many affections 
of which il is« Kympioni ; and tliis i«6 excellently well 
iona by Dr. Smith. The book might fairly be de- 



scribed as a practical handbook of the ccinimon dis- 
ea.ies of children, so numerous are the affectiuiis con- 
sidered either collaterally or directly. We are 
acquainted with no safer guide to the treatment of 
children's diseases, and few works give the insight 
into the physiological and other peculiarities of chil- 
dren that Ur. Smith's book does.— .Brii. Med.Journ., 
April 8, 1871. 



22 Henry C. Lea's Publications — (Diseases of Women). 

/THE OBSTETRICAL JOURNAL. [Free of postage for 1876.) 

THE OBSTETRICAL JOURNAL of Great Britain and Ireland; 

Including Midwifery, and the Diseases of Women and Infants. With an American 
Supplement, edited by J. V. Ingham, M.D. A monthly of about 80 octavo pages, 
very handsomely printed. Subscription, Five Dollars per annum. Single Numbers, 50 
cents each. 

Commencing with April, 187.3, the Obstetrical Journal consists of Original Papers by Brit- 
ish and Foreign Contributors ; Transactions of the Obstetrical Societies in England and abroad ; 
Reports of Hospital Practice: Reviews and Bibliographical Notices; Articles and Notes, Edito- 
rial, Historical, Forensic, and Miscellaneous; Selections from Journals; Correspondence, Ac. 
Collecting together the vast amount of material daily accumulating in this important and ra- 
pidly improving department of medical science, the value of the information which it pre- 
sents to the subscriber may be estimated from the character of the gentlemen who have already 
promised their support, including such names as those of Drs. Atthill, Robert Barnes, Henry 
Bennet, Thomas Chambers, Fleetwood Churchill, Matthews Duncan, Qraily Hewitt, 
Braxton Hicks, Alfred Meadows, W. Leishman, Alex. Simpson, Tyler Smith, Edward J. 
Tilt, Spencer Wells, &c. Ac. ; in short, the representative men of British Obstetrics and Gynae- 
cology. 

In order to render the Obstetrical Journal fully adequate to the wants of the American 
profession, each number contains a Supplement devoted to the advances made in Obstetrics and 
Gynaecology on this side of the All.Tntic. This portion of the Journal is under the editorial 
charge of Dr. J. V. Ingham, to whom editorial communications, exchanges, books for re- 
view, Ac, may be addressed, to the care of the publisher. 

*** Complete sets from the beginning can no longer be furnished, but subscriptions can com- 
mence with January, 1875, or with Vol. II., April, 1874. 



T 



'HOMAS {T.GAILLARD),M.D., 

Pro/efixor of Obstetrics, Ac, in the College of Physicians and Surgeons, If. T., &c. 

A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. Fourth 

edition, enlarged and thoroughly revised. In one large and handsome octavo volume of 
800 pages, with 191 illustrations. Cloth, $5 00; leather, $6 00. (Just Issued.) 

The author has taken advantage of the opportunity afforded by the call for another edition of 
this work to render it worthy a continuance of the very remarkable favor with which it has been 
received. Every portion has been subjected to a conscientious revision, and no labor has been 
spared to make it a complete treatise on the most advanced condition of its important subject. 

A work which has reached a fourth edition, and This volume of Prof. Thomas in its revi.iied form 

that. too. in the short space of five years, has achieved is classicaljwithout being pedantic, full in the details 
a reputation which places it almost beyond the reach I of anatomy and pathology, without ponderous 
of criticism, and the favorable opinions which we have translation of pages of German literature, describes 
already expressed of the former editions seem to re- j distinctly the details and difficulties of each opera- 
quire that we should do little more than announce | tion, without wearying and useless minutije, and is 
this new issue. We cannot refrain from saying that, , in all respects a work wcrthy of confidence, justify- 
as a practical work, this is second to none in the Eng- ing the high regard in which its distinguished an- 
lish. or. indeed, in any other language. The arrange- thor is held by the profession. — Am. Supplement, 
ment of the contents, the admirably clear manner in Obstet. Journ., Oct. 1874. 
which the subject of the ilitferential diagnosis of i 

several of the diseases is handled, leave nothing to be ; Professor Thomas fairly took the Profession of the 
desired by the practitioner who wants a thoroughly ! United States by storm when his book first made its 
clinical work, one to which he can refer in diflSeult i appearance early in 1S6S, Its reception was simply 
ciises of doubtful diagnosis with the certainty of gain- : enthusiastic, notwithstanding a few adverse criti- 
ing light and instruction. Dr. Thomas is a man with a cisms from our transatlantic brethren, the first large 
very clear head and decided view.s. and there seems to , edition was rapidly exhausted, and in six months a 
be nothing which he so much dislikes as hazy notions ; second one was issned, and in two years a third one 
of diagnosis and blind routine and unrea.sonable thera- ' was announced and published, and we are now pro- 
peutics. The student who will thoroughly study this | mised the "fourth. The popularity of this work was 
book and test its principles by clinical observation, will ' not ephemeral, and its success was unprecedented in 
certainly not be guilty of these faults. — London Lancet, \ the annals of American medical literature. .Six years 
Feb. 13, 187.5. ] is a long period in medical scientific research, bal 



_, , . . ..,. ,^,. ,, , ^ .^ , Thomas's work on " Diseases of '.. v.,uou .o o^... -.^ 

The latest edition of this well-known text-book leading native production of the United States.- Th. 

retains the essential characters which rendered the o^der, the matter, the absence of theoretical disputa- 

earliest so deservedly popular It is still pre-emi- tiveness, the fairness of statement, and the elegance 

nently a practical manual intended to convey to ^f diction, preserved throughout the entire range of 

students in a clear and forcible manner a sufficiently , j^g took, indicate that Professor Thomas did not 

complete outline of gynecology. In a word, we I overestimate his powers when he conceived the idea 

should say that any oie who intended to make a and executed the work of producing a new treatise 

special study of gynecology could hardly do better ^^^^ diseases of women.— Prof. Palle.v, in Louis- 

than to begin with a minute perusal of this book, and ^Ug j^^d Journal Sept. lS7-i. 

that any one who intended to keep gyniecology sub- | 

ordinate to general practice, should hardly fail to ; xi^on looking the work over, we think we can ea- 

have It on hand for fnture reference,— JV. Y. Med. , g^y gge whv it should be popular. It is clear and 

Journ., Jan. 1875. ; simple in style, and, in the best sense of the word, 

Reluctantly we are obliged to close this unsatis- ' practical. The arrangement is also natural, and is 

factory notice of so excellent a work, and in conclu- especially full in the therapeutica! department In all 

Hon would remark that, as a teacher of gyn»cology, our reaiiug of such works as this we know of none 

both didactic and clinical, Prof. Thomas hascertainlv ot'i" in any language that has made a more favor- 

taken the lead far ahead of his confrire^, and as an *^'e impression on our mxrxi.-Chicngo Journ. of 

author he certainly has met with unusual and mer- Nervous and Mental dJini ises, Jau ls7a. 
ited success.— ^m, Journ. of Obstttrics, >'ov. 1S74. 



Henry C. Lea's FveTjIOATJO^s— (Diseases of Women). 



TTODGE [HUGH L.), M.D., 

•tl Emeritits Professor of Obstetrics, *e., in the University of Pennsylvania. 

ON DISEASES PECIJLIAR TO WOMEN; including Displacements 

of the uterus. With original illustrations. Second edition, revised and enlarged. In 
one beautifully printed octavo volume of 6.31 pages, cloth, $4 50. 



From, Prof. W. H. Byford, of the Rush Medical 
College, Chicago. 

The book bears the Impress of a master hand, and 
must, as its predecessor, prove acceptable to the pro- 
fession. In diseases of women Dr. Hodge has estab- 
lished a school of treatment that has become world- 
wide in fame. 

Professor Hodge's work is truly an original one 
from beginning to end, consequently no one can pe- 
ruse its pages without learning something new. The 
book, which is by no means a large one, is divided into 
two grand sections, so to speak : first, that treating of 
the nervous sympathies of the uterus, and, secondly. 



that which speaks of the mechanical treatment of dis- 
placements of that organ. He is disposed, as a non- 
Seliever in the frequency of inflammations of the 
uterus, to take strong ground against many of the 
highest authorities in this branch of medicine, and 
the arguments which he offers in support of his posi- 
tion are, to say the least, well put. Numerous wood- 
cuts adorn this portion of the work, and add incalcu- 
lably to the proper appreciation of the variously 
shaped instruments referred to by our author. As a 
contribution to the study of women's diseases, it is of 
great value, and is abutidantly able to stand on its 
own merits.— iV^. Y. Medical Record, Sept. 15, 1868. 



VU'EST [CHARLES), M.B. 

LECTURES ON THE DISEASES OF WOMEN. Third American, 

from the Third London edition. In one neat octavo volume of about 550 pages, cloth, 
$3 75 ; leather, $4 75. 
As a Xvriter, Dr. West stands, in our opinion, se- (seeking truth, and one that will convince the student 
eond only to Watson, the "Macaulay of Medicine;'' i that he has committed himself to acandid, safe, and 
he possesses that happy faculty of clothing instruc- I valuable guide. — N. A. Med.-Ohirurg Review. 
tion In easy garments; combining pleasure with I ,^ , ^ j. -^ ,_ ■ a j j -j ji 4.v 4. i. 

profit, he leads his pupils, in spite of the ancient pro- ! . We have to say of it, briefly and decidedly, that it 
verb, along a royal road to learning. His work is one 1 js the best work on the subject m any language, and 
which will not satisfy the extreme on either side, but I th^* 't ^'^mps Dr. West as the fanleppnceps of 
It is one that will please the great majority who are 



i British obstetric nxLtliOTs.— Edinburgh Med. Journal. 



T>ARNES [ROBERT), M. D., F.R. C.P., 

-*-' Obstetric Physician to St. Thomas's Hospital, &c. 

A CLINICAL EXPOSITION OF THE MEDICAL AND SURGI- 
CAL DISEASES OF WOMEN. In "ue handsome o<^tavo volume of about 800 pages, with 
lfi9 illustrations. Cloth, $5 00; leather, $6 00. (Just Issued.) 
The very complete scope of this volume and the manner in which it has been filled out, may 
be seen by the subjoined Summary of Contents. 

Introduction. Chapter I. Ovaries; Corpus Luteum. II. Fallopian Tubes. III. Shape of 
Uterine Cavity. IV. Structure of Uterus. V. The "Vagina. VI. Examinations and Diagnosis. 
VII. Significance of Leucorrhoea. VIII. Discharges of Air. IX. Watery Discharges. X. Puru- 
lent Discharges. XI. Hemorrhagic Discharges. XII. Significance of Pain. XIII. Significance 
of Dyspareunia. XIV. Significance of Sterility. XV. Instrumental Diiignosis and Treatment. 
XVI. Diagnosis by the Touch, the Sound, the Speculum. XVII. Menstruation and its Disor- 
ders. XVIII. Amenorrhoea. XIX. Amenorrhoea (continued). XX. Dysmenorrhoea. XXI. 
Ovarian Dysraenorrhoea, &c. XXII. Inflammatory Dysmenorrhoea. XXIII. Irregularities of 
Change of Life. XXIV. Relations between Menstruation and Diseases. XXV. Disorders of Old 
Age. XXVI. Ovary, Absence and Hernia of. XXVII. Ovary, Hemorrhage, Ac, of XXVIII. 
Ovary, Tubercle, Cancer, &c., of XXIX. Ovarian Cystic Tumors. XXX. Dermoid Cysts of 
Ovary. XXXI. Ovarian Tumors, Prognosis of. XXXII. Diagnosis of Ovarian Tumors. XXXIII. 
Ovarian Cysts, Treatment of XXXIV. Fallopian Tubes, Diseases of. XXXV. Broad Liga- 
ments, Diseases of. XXXVI. Extra-uterine Gestation. XXXVIT. Special Pathology of Ute 
rus. XXXVIII General Uterine Pathology. XXXIX Alterations of Blood Supply. XL. 
Metritis. Endometritis, Ac. XLI. Pelvic Cellulitis and Peritonitis, Ac. XLII. Hjematqpele, &o 
XLIII. Displacements of Uterus. XLIV. Displacements (continued). XLV. Retroversion and 
Retroflexion. XLVk Inversion. XLVII. Uterine Tumors. XLVIII. Polypus Uteri. XLIX. 
Polypus Uteri (continued). L. Cancer. LI. Diseases of Vagina. LII. Diseases of the Vulva. 



Einbodyingthelongexperience and personal obser- 
vation of one of the greate.st of living teachers in dis- 
eases of women, it seems pervaded by the presence 
of the author, who speakfi directly to the reader, and 
speaks, too, as ono having authority. And yet, not- 
withstanding this distinct personality, there is noth- 
ing narrow as to time, place, or individuals, in the 
views presented, and in the instructions given ; Dr. 
Barnes has been an attentive student, not only of Eu- 
ropean, but also of American literature, pertaining to 
diseases of females, and enricheflyhis own experience 
by ireasnres thence gathered ; he seems as familiar, 
for example, with the writings of Sims, Emmet, Tho- 



mas, and Peaslee, as if these eminent men were his 
countrymen and colleagues, and gives them a credit 
which must be gratifying to every American physi- 
cian.— ylm. Journ. M'ed. Sci., April, 1874. 

Throughout the whole book it is impossible not to 
feel that the author has spontaneously, conscientious- 
ly, and fearlessly performed his task. He goes direct 
to the point, and does not loiter on the way to gossip 
or quarrel with other authors. Dr. Barnes's book 
will be eagerly read all over the world, and will 
everywhere be admired for its comprehensiveness, 
honesty of purpose, and ability — The Ohstet. Journ. 
of Great Britain and Ireland, March, 1874. 



DEWEES'S TREATISE ON THE DISEASES OF FE 
MALES. With illnsirations. Eleventh Edition 
with the Author's last improvementsand correc 
tlouB. In one octavo volume of 636 pages, wltl 
plates, cloth. *.S 00. 

CHURCHILL ON THE P0ERPERAL FEVER AND 
OTHER DISEASES PECULIAK TO WOMEN. 1 vol. 
8vo,, pp. 4J0, cloth, $2 50. 



ASHWELL'S PRACTICAL TREATISE ON THE DIS- 
EASES PECULIAR TO WOMEN. Third American, 
from the Third and revised Loudon edition. 1 vol. 
8vo., pp. .128, cloth. *.l .-50. 

«EIGS ON THE NATURE. SIGNS, AND TREAT- 
MENT OF CHILDBED FEVER. 1 vol. 8vo., pp. 
»e6, oloth. i$a 00. 



24 



Henry C. Lea's Publications — {Midwifery). 



ffODGE [HUGH L.), M.D., 

■*■-'■ Emeritus Profeggor of Midwifery, Ac, in the University of Pennsylvania, Sec. 

THE PRIXCIPLES AND PRACTICE OF OBSTETRICS. HIub- 

trated with large lithographic plates containing one hundred and fifty-nine figures from 

original photographs, and with numerous wood-cuts. In one large and beautifully printed 

quarto volume of 550 double-columned pages, strongly bound in cloth, $14. 

The work of Dr. Hodge is Komething more than a, We have examined Professor Hodge's work witli 

•Imple presentation of his particular views in the de- great satisfaction; every topic is elaborated most 

partment of Obstetrics ; it is something more than an i fully. The views of the author are comprehensive, 

iry treatise on midwifery ; it is, in fact, a cyclo- and concisely stated. The rules of practice are jndi- 

id will enable the practitioner to meet every 



arican press.— PacyJc 
> Med. and Surg. Journal, July, 1864. 



ordi 

Dicdia of midwifery. He has aimed to embody in a 

single volume the whole scienceand art of Obstetrics, ^emergency of obstetric complication with oonfidenoe. 

An elaborate text is combined with accurate and va Chicago Med. Journal, Aug. 1864. 

ried pictorial illustrations, so that no fact or principle 

Ib left unstated or unexplained.— ^m. Med. Times, "ore time than we have had at our disposal sine* 

Sept. .3, 1S64. '^^ received the great work of Dr. Hodge is necessary 

Tvr u ,j >., . . .,_ - J. *if to do it iastice. It is undoubtedly by far the most 

We should like to analyze the remainder of this original, complete, and carefully composed treatis. 
excellent work, but already has this review extended „^«^^ principles akd practice of Obstetrics which has 
beyond our bmited space. We cannot conclude this ^^^^ J^^ .J^^^ ^^^^ the Ar - 

BOtice without referring to the excellent finish of the 
work. In typography it is not to be excelled ; the 
paper is superior to what is usually afforded by our| We have read Dr. Hodge's book with great plea- 
American cousins, quite equal to the best of English Ig^re, and have much satisfaction in expressing oni 
books. The engravings and lithographs are most i commendation of it as a whole. It is certainly highly 
beautifully executed. The work recommends itself instructive, and in the main, we believe, correct. The 
for Its originality, and is in every way a most valn-l great attention which the author has devoted to the 
able addition to those on the subject of obstetrics.- : mechanism of parturition, taken along with the con- 
Oanada Med. Journal. Oct. 1864. | elusions at which he has arrived, point, we think, 

It is very large, profusely and elegantly illustrated, conclusively to the fact that, in Britain at least, tb« 
and is fitted to take its place near the works of great doctrines of Naegele have been too blindly received. 
obstetricians. Of the American works on the fiVih]e.ct\— Glasgow Med. Journal, Oct. 1864. 
It is decidedly the best.— Brfinft. Med. Jour., Dec. '64. 

*** Specimens of the plates and letter-press will be forwarded to any address, free by mail, 
on receipt of six cents in postage stamps. 



JUNNER {THOMAS H.), M. D. 
Oi\ THE SIGNS AND DISEASES OF PREGNANCY. Fin-t American 

from the Second and Enlarged English Edition. With four colored plates and illustrations 
on wood. In one handsome octavo volume of about 500 pages, cloth, $4 25. 
The very thorough revision the work has undergone pregnancy, but always ready to treat all the nume- 
rous ailments that are, unfortunately for the civilized 
women of to-day, so commonly associated with the 
function.- iV^. Y. Med. Record. March 16, 1S68. 

We recommend obstetrical students, young and 
old, to have this volume in their collections. It con- 
tains not only a fair statement of the signs, symptoms, 
and diseasef of pregnancy, but comprises in addition 
much interesting relative matter that is not to be 
found in any other work that we can n.a,m6.— Edin- 
burgh Med Journal, Jan. 1868. 



has added greatly to its practical value, and increased 
materially its efficiency as a guide to the student and 
to the young practitioner. — Am. Journ. Med. Sci., 
April, 1868. 

With the immense variety of subjects treated of 
and the ground which they are made to cover, the im- 
possibility of giving an extended review of this truly 
remarkable work must be apparent. We have not a 
single fault to find with it, and most heartily com- 
mend it to the careful study of every physician who 
would not only always be' sure of his diagnosis of 



QWAFiVE {JOSEPH GRIFFITHS), M. D., 

'^ Physieian-Arcoiiclicur to the Britixh General Ho.spital, &e. 

OBSTETRIC APHORISMS FOR THE USE OF STUDENTS COM- 

MENCING MIDWIFERY PRACTICE. Second American, from the Fifth and Revised 
London Edition, with Additions by E. R. Hutchins, M. D. With Illustrations. In one 
neat 12mo. volume. Cloth, $1 25. {Lately Issued.) 
*i* ^e p. .3 of this Catalogue for the terms on which this work is offered as a premium to 
subscribers to the " American Journal of the Medical Sciences." 

It is really a capital little compendium of the sub- ' answers the purpose. It is lot only valuable for 
Ject, and we recommend young practitioners to buy it ! young beginners, but no one who is not a proficient 
and carry it with them when called to attend cases of | in the art of obstetrics should be without it, because 

■ it condenses all that is necessary to know for ordi- 

nary midwifery practice. We commend the book 
most favorably.— S<. Louis Med. and Surg. Journal, 
Sept. 10, 1870. 

A studied perusal of this little book has satisfied 
us of Its eminently practical value. The object of the 
work, the author says, in his preface, is to give the 
student a few brief and practical directions respect- 
ing the management of ordinary cases of labor ; and 
also to point out to him in extraordinary cases when 
and how he may act upon his own responsibility, and 
when he ought to send for assistance. — If. T. Medical 
Journal, May, 1870 



labor. They can while away the otherwise tedious 
hours of waiting, and thoroughly fix in their memo- 
ries the most important practical suggestions it con- 
tains. The American editor has materially added by 
his notes and the concluding chapters to the com- 
pleteness and general value of the book. — Chicago 
Med. Journal, Feb. 1870. 

The manual before nscontainsin exceedingly small 
compass — small enough to carry in the pocket — about 
all there is of obstetrics, condensed into a nutshell of 
Aphorisms. The illustrations are well selected, and 
serve as excellent reminders of the conduct of labor — 
regular and difficult.- CinctnTiatt Lanct, April, '70, 

'"biBi8amostadmirahlelittlework,andcomplete]y 



w 



INCKEL (F.). 

Professor and Director of the Gynecological Clinic in the Oniver.iiftj of Rostock. 

A COMPLETE TREATISE ON THE PATHOLOGY AND TREAT- 

M£NT OF CHILDBED, for Students and Practitioners. Tran.slated, with the consent of 
the author, from the Second German Edition, by James Read Chadwick, M D. In one 
octavo volume. (Preparing.) 



HiNBY C. Lsa'8 FvbJjIOAHIO^b— (Midwifery). 



§5 



TEISEMAN [WILLIAM), M.D., 

"^ Regius Professor of Midwifery in the University of Glasgow, &c. 

A SYSTEM OF MIDWIFERY, INCLUDING THE DISEASES OF 

PREGNANCY AND THE PUERPERAL STATE. Second American, from the Second 
and Revised English Edition, with additions by John S. Parby, M.D., Obstetrician to the 
Philadelphia Hospital, &c. In one large and very handsome octavo volume of over 700 
pages, with about two hundred illustrations. {PreparMig.) 



TMb is one of a most coinplete aud exhaustive cha- 
racter. We have gone carefully through it, and there 
is no subject in Obstetrics which has not been con- 
sidered well and fully. The result is a work, not 
only admirable as a text-book, but valuable as a work 
of reference to the practitioner in the various emer- 
gencies of obstetric practice. Take it all in all, we 
have no hesitation in saying that it is in our j ndgment 
the best English work on the subject. — London Lan- 
cet, Aag. 23,1873. 

The work of Leishman gives an excellent view of 
modern midwifery, and evinces its author's extensive 
acquaintance with British and foreign literature ; and 
not only acquaintance with it, but wholesome diges- 
tion and sound judgment of it. He has, withal, a 
manly, free style, and can state a difficult and compli- 
cated matter with remarkable clearness and brevity. 
—Bdin. Med. Journ., Sept. 1S73. 

The author has succeeded in presenting to the pro- 
fession an admirable treatise, especially in its practi- 
cal aspects ; one which is, in general, clearly written, 
and sound in doctrine, and one which cannot fail to 
add to his already high repatation. In concluding 
our examination of this work, we cannot avoid again 
Baying that Dr. Leisbman has fully accomplished 
that diHcalt task of presenting a good text-book upon 
obstetrics. We know none better for the use of the stu- 
dent or junior practitioner. — Am. Practitioner, Mar. 
1874. 

It proposes to offer to practitioners and students 



"A Complete System of the Midwifery of the Present 
Day," and well redeems the promise. In all that 
relates to the subject of labor, the teaching is admi- 
rably clear, concise, and practical, representing not 
alone British practice, but the contributions of Con- 
tinental and American schools. — N. Y. Med. Record, 
March 2, 1S7-1. 

The work of Dr. Leishman is, in many respects, 
not only the best treatise on midwifery that we have 
seen, but one of the best treatises on any medical sub- 
ject that has been published of late years. — Lond. 
Practitioner, Feb. 187i. 

It was written to supply a desideratum, and we will 
be much surprised if it does not fulfil the purpose of 
its author. Taking it as a whole, we know of no 
work on obstetrics by an English author in which the 
student and the practitioner will find the information 
so clear and so completely abreast of the present state 
of our knowledge on the subject. — Glasgow Med. 
Journ., Aug. 1S73. 

Dr. Leishmau's System of Midwifery, which has 
only just been published, will go far to supply the 
want which has so long been felt, of a really good 
modern English text-book. Although large, as is in- 
evitable in a work on so extensive a subject, it is so 
well and clearly written, that it is never wearisome 
to read. Dr. Leishman's work may be confidently 
recommended as an admirable text-book, and is sure 
to be largely used.— Lond. Med. Record, Sept. 1S73. 



n 



AMSBOTEAM [FBANGIS H.), M.D. 

THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI- 

CINE AKD SURGERY, in reference to the Process of Parturition. A new and enlarged 
edition, thoroughly revised by the author. With additions by W. V. Keating, M. D., 
Professor of Obstetrics, &c., in the Jefferson Medical College, Philadelphia. In one large 
and handsome imperial octavo volume of 650 pages, strongly bound in leather, with raised 
bands ; with sixty-four beautiful plates, and numerous wood-cuts in the text, containing in 
" " ■ $7 00. 

To the physician's library it is indispensable, while 
to the student, as a text-book, from which to extract 
the material for laying the foundation of an education 
on obstetrical science, it has no superior. — Ohio Med. 
and Surg. Journal. 

When we call to mind the toil we underwent in 
acquiring a knowledge of this subject, we cannot bat 
envy the student of the present day the aid which 
this work will afford him. — Am. Jour, of the Med. 
Sciences. 



all nearly 200 large and beautiful figures. 

We will only add that the student will learn from 
It all he need to know, and the practitioner will find 
it, as a book of reference, surpassed by none other. — 
Stethoscope. 

The character and merits of Dr. Eamsbotham's 
work are so well known and thoroughly established, 
that comment is unnecessary and praise superfluous. 
The illustrations, which are numerous and accurate, 
are executed in the highest style of art. We cannot 
too highly recommend the work to our readers. — St. 
houis Med. and Surg. Journal. 



fJHURCHILL [FLEETWOOD), M.D., M.R.I. A. 

ON THE THEORY AND PRACTICE OF MIDWIFERY. A new 

American from the fourth revised and enlarged London edition. With notes and additions 
by D. Francis Condie, M. D., author of a "Practical Treatise on the Diseases of Chil- 
dren,'' Ac. With one hundred and ninety-four illustrations. In one very handsome octavo 
volume of nearly 700 large pages. Cloth, $4 00; leather, $5 00. 



OARRY [JOHN S.), M.D., 

Obttntrician to the Philadelphia Hospital, Vice-Prest. nf the Ohsitt. S->ciety of Philadelphia 

EXTRA-UTERINE PREGNANCY: ITS CLINICAL HISTORY, 

DIAGNOSIS, PROGNOSIS, AND TREATMENT. In one handsome octavo volume. 
{Prepari7ig.) 



MONTGOMERY'S EXPOSITION OF THE SIGNS 
AND SYMPTOMS OF PREGNANCY. With two 
exquisite colored plates, and numerous wood-cuts. 
In 1 vol. 8vo., of nearly 600 pp., cloth. $3 75. 



aiGBY'S SYSTEM OP MIDWIFERY. With Notes 
and Additional Illustrations. Second American 
edition. One volume octavo, cloth, 422 pages. 
<3 60. 



26 



Henry C. Lea's Publications — (Surgery). 



^IROSS {SAMUEL D.), M.D., 

^^ Pro/tssor of Surgery in the Jefferson Medical College of Philadelphia. 

A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, 

and Operative. Illustrated by upwards of Fourteen Hundred Engravings. Fit'tli edition, 
carefully revised, and improved. In two large and beautifully printed imperial octavo vol- 
umes of about 2300 pages, strongly bound in leather, with raised bands, $16. {Just Issued.) 
The continued favor, shown by the exhaustion of successive large editions of this great work, 
proves that it has successfully supplied a want felt by American practitioners and students. In the 
present revision no pains have been spared by the author to bring it in every respect fully up to 
the day. To effect this a large part of the work has been rewritten, and the whole enlarged by 
nearly one-fourth, notwithstanding which the price has been kept at its former very moderate 
rate. By the use of a close, though very legible type, an unusually large amount ol matter is 
condensed in its pages, the two volumes containing as much as four or five ordinary octavos. 
This, combined with the most careful mechanical execution, and its very durable binding, renders 
it one of the cheapest works accessible to the profession. Every subject properly belonging to the 
domain of surgery is treated in detail, so that the student who possesses this work may be said to 
have in it a surgical library. A few notices of the previous edition are subjoined : — 

It must long remain the most comprehensive work hesitation in prououncing it without a rival in our 



1 believe it 



on this important part of medicine. — Boston Medical 
and SurgicalJournal, March 'I'i, IStJJ. 

We have compared it with most of our standard 
works, sach as those of Erichsen, Miller, Fergusson, 
Syme, and others, and we must, in justice to our 
author, award it the pre-eminence. As a work, com- 
plete in almost every detail, no matter how minute 
or trilling, and embracing every subject k 
the principles and practice of surgery 
stands without a rival. Dr. Gross, in his preface, re- 
marks "my aim has been to embrace the whole do- 
main of surgery, and to allot to every subject its 
legitimate claim to notice;" and, we assure our 
readers, he has kept his word. It is a work which 
we can most confidently recommend to our brethren, 
for its utility is becoming the more evident the longer 
It is upon the shelves of our library. — Canada Med. 
Journal, September, 1865. 

The first two editions of Professor Gross' System of 
Surgery are so well known lo the profession, and so 
highly prized, that it would be idle for us to speak in 
praise of this work.— Chicago Medical Journal, 
September, 1865. 

We gladly indorse the favorable recommendation 
of the work, both as regards matter and style, which 
we made when noticing its first appearance.— .BriiiA'/i 
and Foreign Medico-Chirurgieal Review, Oct. 1865. 

The most complete work that has yet issued from 
the press on the science and practice of surgery.- 
London Lancet. 

This system of surgery is, we predict, destined to 
take a commanding position in our surgical litera- 
ture, and be the crowning glory of the author's well 
earned fame. As an authority on general surgical 
subjects, this work is long to occupy a pre-eminent 
place, not only at home, but abroad. We have no 
UY THE SAME AUTHOR. 

A PRACTICAL TREATISE ON FOREIGN BODIES IN THB 

AIR-PASSAGES. In 1 vol. 8vo., with illustrations, pp. 468, cloth, $2 75. 



equal to the best systems of surgery in 
any language. — N. Y. Med. Journal. 

Not only by far the best text-book on the subject, 
as a whole, within the reach of American students, 
but one which will be much more than ever likely 
to be resorted to and regarded as a high authority 
abroad. — Am. Journal Med. Sciences, Jan. 1865. 

The work contains everything, minor and major, 
operative and diagnostic, including mensuration and 
examination, venereal diseases, and uterine manipu- 
lations and operations. It is a complete Thesaurus 
of modera surgery, where the student and practi- 
tioner shall not seek in vain for whai they desire.— 
San Francisco Med. Press, Jan. 1865. 

Open it where we may, we find sound practical In- 
formation conveyed in plain language. This book it 
no mere provincial or even national system of sur- 
gery, but a work which, while very largely indebted 
to the past, has a strong claim on the gratitude of tlie 
future of surgical science. — Edinburgh Med. Journal, 
Jan. 1865. 

A glance at the work is sufficient to show that the 
author and publisher have spared no labor in making 
it the most complete "System of Surgery" ever pub- 
lished in any country. — St. Louis Med. and Surg. 
Journal, April, 1865. 

A system of surgery which we think unrivalled m 
our language, and which will indelibly associate his 
name with surgical science. And what, in our opin- 
ion, enhances the value of the work is that, while the 
practising surgeon will find all that he requires in it, 
it is at the same time one of the most valuable trea- 
tises which can be put into the hands of the student^ 
seeking to know the principles and practice of this 
branch of the profession which he designs subse- 
quently to follow. — The Brit. Am.Journ., Montreal. 



SKET'S OPERATIVE SURGERY. In 1 vol. 8to. 

cloth, of over 650 pages ; with aboutlOO wood-cuts. 

$3 25. 
COOPER'S LECTURES ON THE PRINCIPLES AND 

Practice of Surgekt. In 1 vol. 8vo. cloth, 750 p. |2. 



GIBSON'S INSTITUTES AND PRACTICE OF SUR- 
GERY. Eighth edition, improved and altered. With 
thirty-four plates. In two handsome octavo vol- 
umes, about 1000 pp., leather, raised bandt. $6 80. 



MJLLER {JAMES), 

J,IL Late Professor of Surgery in the University of Edinburgh, &c. 

PRINCIPLES OF SURGERY. Fourth American, from the third and 

revised Edinburgh edition. In one large and very beautiful volume of 700 pages, with 
two hundred and forty illustrations on wood, cloth, $3 75. 

DY THE SAME AUTHOR. 

THE PRACTICE OF SURGERY. Fourth American, from the last 

Edinburgh edition. Revised by the American editor. Illustrated by three hundred and 
sixty-four engravings on wood. In one large octavo volume of nearly 700 pages, cloth, 
$3 75. 

QAROENT {F. W.), M.D. 
^ ON BANDAGING AND OTHER OPERATIONS OF MINOR 

SUR&ERY. New edition, with an additional chapter on Military Surgery. One handsome 
royal l2mo. volume, of nearly 400 pages, with 184 wood-outs. Cloth, $1 76 



Henry C. Lea's Publications — (Surgery). 



2t 



ASHHURST {JOHN, Jr.), M.D., 

Surgeon to the Episcopal Hospital, Philadelphia. 

THE PRINCIPLES AND PRACTICE OF SURGERY. In one 

very large and handsome octavo volume of about 1000 pages, with nearly 550 illustrations, 

cloth, $6 50; leather, raised bands, $7 50. {Lately Published.) 
The object of the author has been to present, within as condensed a compass as possible, a 
complete treatise on Surgery in all its branches, suitable both as a text-book for the student and 
a work of reference for the practitioner. So much has of late years been done for the advance- 
ment of Surgical Art and Science, that there seemed to be a want of a work which should present 
the latest aspects of every subject, and which, by its American character, should render accessible 
to the profession at large the experience of the practitioners of both hemispheres. This has been 
the aim of the author, and it is hoped that the volume will be found to fulfil its purpose satisfac- 
torily. 

Its author has evidently tested the writings and 
experiences of the past and present in the crucible 
of a careful, analytic, and honorable mind, and faith- 
fully endeavored to bring his work up to the level of 
the highest standard of practical surgery. He is 
frank and definite, and gives us opinions, and gene- 
rally sound ones, instead of a mere resume of the 
opinions of others. He is conservative, but not hide- 
bound by authority. His style is clear, elegant, and 
scholarly. The wcrk is an admirable tex-tbook, and 
a useful book of reference It is a credit to American 
professional literature, and one of the first ripe fruits 
of the soil fertilized by the blood of our late unhappy 
war.— A', r. Med. Record, Feb. 1, 1S72. 



, the work as a whole must be regarded as 
an excellent and concise exponent of modern sur- 
gery, and as such it will be found a valuable text- 
book for the student, and a useful hook of reference 
for the general practitioner. — N. Y. Med. Journal, 
Feb. 1872. 

It gives us great pleasure to call the attention of the 
profession to this excellent work. Our knowledge of 
its talented and accomplished author led us to expect 
from him a very valuable treati&e upon subjects to 
which he has repeatedly given evidence of having pro- 
fitably devoted much time and labor, and we are in no 
way disappointed.— P;iaa. Med. Times,Fe\>. 1,1872. 



JJOLMES {TIMOTHY), M.D., 

Surgeon to St. George's Hospital, London. 

SURGERY, ITS PRINCIPLES AND PRACTICE. In one hand- 

some octavo volume of about 800 pages, with over 400 illustrations. {Nearly Ready.) 



piRRIE { WILLIAM), F. R. S. E., 

.*■ Professor of Sitrgery in the University of Aberdeen. 

THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by 

John Neill, M. D., Professor of Surgery in the Penna. Medical College, Surgeon to the 
Pennsylvania Hospital, &c. In one very handsome octavo volume of 780 pages, with 3] 6 
illustrations, cloth, $3 76. 



TJAMILTON {FRANK H.), M.D., 

Professor of Fractures and Dislocations, &c., in Bellevue Hosp. Med. College, New York. 

A PRACTICAL TREATISE ON FRACTURES AND DISLOCA- 
TIONS. Fifth edition, revised and improved. In one large and handsome octavovoluire 
of nearly 800 pages, with 344 illustrations. Cloth, $5 75 ; leather, $6 75 {Nearly Ready. 

This work is well known, abroad as well as at home, as the highest authority on its important 
subject — an authority recognized in the courts as well as in the schools and in practice — and 
again manifested, not only by the demand for a fifth edition, but by arrangements now in pro- 
gress for the speedy appearance of a translation in Germany. The repeated revisions which the 
author has thus had the opportunity of making have enabled him to give the most careful consid- 
eration to every portion of the volume, and he has sedulously endeavored in the present issue, 
to perfect the work by the aid of his own enlarged experience and to incorporate in it whatever 
of value has been added in this department since the issue of the fourth edition. It will there- 
fore be found considerably improved in matter, while the most careful attention has been paid 
to the typographical execution, and the volume is presented to the profession in the confident 
hope that it will more than maintain its very distinguished reputation. 

A few notices of the previous edition are subjoined : — 

frof. Hamilton has a world-wide reputation as the 
author of a Treatise oq Fractures and Dislocations, 
which it is safe to say has no equal in the English 
language. — Buffalo Med. and Surg. Journ., Nov. 



The best work on the subject nowpubli«hed.— ylin. 
Jnnrn. of Med. Sci., .Jan. 1873. 

It is undoubtedly the best on tho.se subjects in the 
English language — Nashville Med. and Surg. 
Journ., Dec. 1872. 

it is not, of course, our intention to review, in ex- 
tenso, Hamiltou on "Fractures and Dislocations, " 
Eleven years ago such review might not have tieen 
OTit of place ; to-<lay the work is an authority, so well, 
su generally, and so fH,vorably known, tlmt it only 
remains for the reviewer to say that a new edition is 
Just out, and it is better than either of its predeces- 
»&Ta.— Cincinnati Clinic, Oct. 14, 1871. 



Undoubtedly the best work on Fractures and Dis" 
locatioQs in the English language. — Cincinnati Med- 
Repertory, Oct. 1871. 



We have once more before us Dr. Hamilton's admi- 
rable treatise, which we have always considered the 
most complete and reliable work on the subject. As 
a whole, the work is without an equal in the litera- 
ture of the profession. — Boston Med. and Surg. 
Journ., Oct. 12, 1871. 

It is unnecessary at this time tocommend the book, 
except to such as are beginners in the study of this 
particular branch of surgery. Every practical sur- 
geon in this country and abroad knows of it as a most 
trustworlliy guide, and one whicli they, in common 
with us, would unqualifiedly recommeirt as the high- 
est authority in any language. — N. Y. Med. Record, 
Oct. 16, 1871. 



28 Henry C. Lea's Publications — (Surgery). 

UIRICHSEN {JOHN E.), 

•*-' Professor of Surgery in University College, London, etc. 

THE SCIEXCE AND ART OF STIRGEIIY; being a Treatise on Sur- 

gical Injuries, Diseases, and Operations. Revised by the nuthor from the Sixth and 
enlarged English Edition. Illustrated by over seven hundred engravings on wood. In 
two large and beautiful octavo volumes of over 1700 pages, cloth, $9 00 ; leather, $11 00. 
(Lately Issited.) 

Aietkor's Prf-face to the New American Edition. 

" The favorable reception with which the ' Science and Art of Surgery' ha.s been honored by the 
Surgical Profession in the United States of America has been not only a source of deep gratifica- 
tion and of just pride to me, but has laid the foundation of many professional friendships that 
are amongst the agreeable and valued recollections of my life. 

"I have endeavored to make the present edition ofthis work more deserving than its predecessors 
of the favor that has been accorded to them. In consequence of delays that have unavoidably 
occurred in the publication of the Sixth British Edition, time has been afforded to me to add to this 
one several paragraphs which I trust will be found to increase the practical value of the work." 
LoNDOS, Oct. 1S72. 

On no former edition of this work has the author bestowed more pains to render it a complete and 
satisfactory exposition of Briti.'sh Surgery in its modern aspects. Every portion has been sedu- 
lously revised, and a large number of new illustrations have been introduced. In addition to the 
material thus added to the English edition, the author has furnished for the American edition such 
material as has accumulated since the passage of the sheets through the press in London, so that 
the work as now presented to the American profession, contains his latest views and experience. 

The increase in the size of the work has seemed to render necessary its division into two vol- 
umes. Great care has been exercised in its typographical execution, and it is confidently pre- 
sented as in every respect worthy to maintain the high reputation which has rendered it a stand- 
ard authority on this department of medical science. 

These are only a few of the points in which the states in his preface, they are not confined to any one 
present edition of Mr. Erichsen's work surpasses its j portion, but are distributed generally through the 
predecessors. Throughout there is evidence of a ; subjects of which the work treats. Certainly one of 
laborious care and solicitude in seizing the passing! the most valuable sections of the book seems to us to 
knowledge of the day, which reflects the greatest I be that which treats of the diseases of the arteries 
credit on the author, and much enhances the value ; and the operative proceedings which they necessitate 
of his work. We can only admire the industry which j In few text-books is so much carefully arranged in- 
has enabled Mr. Erichsen thus to succeed, amid the formation collected. — London 3Ied. Times and Oaz., 
distractionsof active practice, in producing emphatic- | Oct. 26, 1872. 

allyxHEbookof reference andstudyfor British prac- ; Tj,e entire work, complete, as the great English 
titioners of surgery— London Lancet, Oct. 26, 1872. treati.se on Surgery of our own time, is, we can assure 

Considerable changes have been made in this edi- ' our readers, equally well adapted for the most junior 
lion, and nearly a hundred new illustrations have student, and, as a book of reference, for the advanced 
been added. Itisdifflcult in a small compass to point } practitioner — Dublin Quarterly Journal. 
out the alterations and additions; for, as the author I 

fiRUITT [ROBERT), M.R.C.S.. *v. 

THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. 

A new and revised American, from the eighth enlarged and improved London edition. Illus- 
trated with four hundred and thirty -two wood engravings. In one very handsome octavo 
volume, of nearly 700 large and closely printed pages, cloth, $4 00 ; leather, $5 00. 



All that the surgical student or practitioner could 
desire. — Dublin Quarterly Journal. 

It is a most admirable book. We do not know 
when we have examined one with more pleasure. — 
Boston Med. and Surg. Journal. 

In Mr. Druitt's book, though containing only some 
seven hundred pages, both the principles and the 



practice of surgery are treated, and so clearly and 
perspicuously, as to elucidate every important topic. 
We have examined the book most thoroughly, and 
can say that this success is well merited. His book, 
moreover, possesses the inestimable advantages of 
having the subjects perfectly well arranged and clas- 
sified, and of being written in a style at once clear 
md succinct. — Am. Journal of Med. Sciences. 



ASHTON [T. J.). 
ON THE DISEASES, INJURIES, AND MALFORMATIONS OF 

THE RECTUM AND ANUS; with remarks on Habitual Constipation. Second American, 
from the fourth and enlarged London edition. With handsome illustrations. In one very 
beautifully printed octavo volume of about 300 pages, cloth, $3 25. 



BIGELO W [HENRY J.), M. D., 
Professor of Surgery in the Massach^isetts Med. College. 

ON THE MECHANISM OF DISLOCATION AND FRACTURE 

OF THE HIP. With the Reduction of the Dislocation by the Flexion Method. With 
numerous original illustrations. In one very handsome octavo volume. Cloth, $2 50. 

TA WSON [GEORGE), F. R. C. S., Engl., 

^^ Assistant Surgeon to the Roynl London Ophthalmic Sospital, Moorfields, &c. 

INJURIES OF THE EYE, ORBIT, AND EYELIDS: their Imme- 

diate and Remote Effects. With about one hundred illustrations. In one very hand- 
some octavo volume, cloth, $3 50 
It is an admirable practical book in the highett and b°5>t senoif. of th? phrr.ge. —ion^on Medical Timet 
and Gazette, May 18. 1867. 



Henry C. Lea's Publioations— (^wrorer^). 



29 



B 



BYANT {THOMAS), F.B.C.S., 

Stirgeon to Guy's Hospital. 

THE PRACTICE OP SUUGERY. 



With over Pive Hundred En- 



gravings on Wood. In one large and very handsome octavo volume of nearly 1000 pages, 
cloth, $6 25 ; leather, raised bands, $7 25. {Lately Published.) 



Again, the author gives us his own practice, his 
own beliefs, and illustrates by his own cases, or those 
treated in Guy's Hospital. This feature adds joint 
emphasis, and a solidity to his statements that inspire 
confidence. • One feels himself almost by the side of 
the surgeon, seeing his work and hearing his living 
words. The views, etc., of other surgeons are con- 
sidered calmly and fairly, but Mr. Bryant's are 
adopted. Tlius the work is not a compilation of 
other writings; it is not an encyclopsedia, but the 
plain statements, on practical points, of a man who 
has lived and breathed and had his being in the 
richest surgical experience. The whole profession 
owe a debt of gratitude to Mr. Bryant, for his work 
in their behalf. We are confident that the American 
profession will give substantial testimonial of their 
feelings towards both author and publisher, by 
speedily exhausting this edition. We cordially and 
heartily commend it to our friends, and think that 
no live surgeon can atford to be without it. — Detroit 
Review of 3Ied. and Pharmacy, August, 1S73. 

As a manual of the practice of surgery for the use 
of the student, we do not hesitate to pronounce Mr. 
Bryant's book a first-rate work. Mr. Bryant has a 
good deal of the dogmatic energy which goes with 
the clear, pronounced opinions of a man whose re- 
flections and experience have moulded a character 
not wanting in firmness and decision. At the same 
time he teaches with the enthusiasm of one who has 
faith in his teaching; he speaks as one having au- 
thority, and herein lies the charm and excellence of 
his work. He states the opinions of others freely 



and fairly, yet it is no mere compilation. The book 
combines much of the merit of the manual with the 
merit of the monograph. One may recognize in 
almost every chapter of the ninety-four of which the 
work is made up the acuteness of a surgeon who has 
seen much, and observed closely, and who gives forth, 
the results of actual experience. In conclusion we 
repeat what we stated at fir.'^t, that Mr. Bryant's book 
is one which we can conscientiously recommend both 
to practitioners and students as an admirable work. 
— Dublin Journ. of 3Ied. Science, August, 1873. 

Mr. Bryant has long been known to the reading 
portion of the profession as an able, clear, and graphic 
writer upon surgical subjects. The volume before 
us is one eminently upon the practice of surgery and 
not one which treats at length on surgical pathology, 
though the views that are entertained upon tnis sub- 
ject are sufficiently interspersed through the work 
for all practical purposes. As a text-book we cheer- 
fully recommend it, feeling convinced that, from the 
subject-matter, and the concise and true way Mr. 
Bi-yaut deals with his subject, it will prove a for- 
midable rival among the numerous surgical text- 
books which are offered to the student. — N. Y. Med, 
Record, June, 1873. 

This is, as the preface states, an entirely new book, 
and contains in a moderately condensed form all the 
surgical information necessary to a general practi- 
tioner. It is written in a spirit consistent with the 
present improved standard of medical and surgical 
science. — American Journal of Obstetrics, August, 
1S73. 



l^ELLS [J. SOELBERG), 

» ' Professor of Ophthalmology in King's College Hospital, &c. 

A TREATISE ON DISEASES OP THE EYE. Second American, 

from the Third and Revised London Edition, with additions; illustrated with numerous 
engravings on wood, and six colored plates. Together with selections from the Test-types 
of Jaeger and Snellen. In one large and very handsome octavo volume of nearly 800 
pages ; cloth, ,$5 00 ; leather, $6 00. {Lately Ptcblisked.) 
The continued demand for this work, both in England and this country, is sufficient evidence 
that the author has succeeded in his effort to supply within a reasonable compass n full practical 
digest of ophthalmology ia its most modern aspects, while the call for repeated editions has en- 
abled him in his revisions to maintain its position abreast of the most recent investigations and 
improvements. In again reprinting it, every effort has been made to adapt it thoroughly to the 
wants of the American practitioner. Such additions as seemed desirable have been introduced 
by the editor, Dr. I. Minis Hays, and the number of illustrations has been largely increased. The 
importance of test-types as an aid to diagnosis is so universally acknowledged at the present day 
that it seemed essential to the completeness of the work that they should be added, and as the 
author recommends the use of those both of Jaeger and of Snellen for different purposes, selec- 
tions have been made from each, so that the practitioner may have at command all the assist- 
ance necessary. Although enlarged by one hundred pages, it has been retained at the former 
very moderate price, rendering it one of the cheapest volumes before the profession. 
A few notices of the previous edition are subjoined. 

On examining it carefully, one is not at all sur- lucid and flowing, therein differing materially from 

some of the translations of Continental writers on this 
subject that are in the market. Special pains are 
taken to explain, at length, those subjects which are 
particularly difljcult of comprehension to the begin- 
ner, as the use of the ophthalmoscope, the interpre- 
tation of its images, etc. The book is profusely and 
ably illustiated, and at the end are to be found 16 
excellent colored ophthalmoscopic figures, which are 
copies of some of the plates of Liebreich's admirable 
atlas. — Kansas City Med. Journ., June, 187i. 



prised that it should meet with universal favor. It 
is, in fact, a comprehensive and thoroughly practical 
treatise on di.^ieases of the eye, setting forth the prac- 
tice of the leading oculists of Europe and America, 
and giving the author's own opinions and preferences, 
which are quite decided and worthy of high consid- 
eration. The third English edition, from which this 
is taken, having been revised by the author, com- 
prises a notice of all the more recent advances made 
in ophthalmic science. The stylo of the writer is 



fA UBENCE {JOHN Z.), F. B. G. S., 

Editor of the Ophthalmic Review, &c. 

A IIANDY-JJOOK OP OPHTHALMIC SURGERY, for the use of 

Practitioners. Second Edition, revised and enlarged. With numerous illustrations. In 

one very handsome octavo volume, cloth, $2 75. 
For those, however, who must assume the care of i edition those novelties which have secured the confi- 
diseases and injuries of the eye, and who are too dence of the profession since the appearance of his 
much pressed for time to study the classic works on last. The volume has been considerably enlarged 
the subject, or those recently published by .Stellwag, and improved by the revision and additions of its 
Wells, Bader, and otht^rs, Mr. Laurence will prove a author, expressly for the Amoricao edition. — Am. 
safe and trustworthy guide. He has described in this I Journ. Med. Sciences, Jan. 1870. 



30 Henry C. Lba's Publications — (Surgeryj &c.). 

rpHOMPSON {SIR HENR Y), 

•* Surgeon and Professor of Clinical Surgery to University College Hospital. 

LECTURES ON DISEASES OF THE TIRINARY ORGANS. With 

illustrations on wood. Second American from the Third English Edition. In one neat 

octavo volume. Cloth, $2 25. (Just Issued.) 
My aim has been to produce in the smallest possible compass an epitome of practical knowl- 
edge concerning the nature and treatment of the diseases which form the subject of the work ; 
and I venture to believe that my intention has been more fully realized in this volume than in 
either of its predecessors. — Author^ s Preface. 

fJT THE SAME AUTHOR. ~~ 

ON THE PATHOLOGY AND TREATMENT OF STRICTURE OF 

THE URETHRA AND URINARY FISTULA. With plates and wood-cuts. From the 
third and revised English edition. In one very handsome octavo volume, cloth, $3 50. 
{Lately Published.) 
T>Y THE SA3IE AUTHOR. {Just Issued.) 

THE DISEASES OF THE PROSTATE, THEIR PATHOLOGY 

AND TREATMENT. Fourth Edition, Revised. In one very handsome ootavo volume of 
365 pages, with thirteen plates, plain and colored, and illustrations on wood. Cloth, $3 75. 



/TAYLOR {ALFRED S.), M.D., 

•*■ Lecturer on Med. Jiirisp. and Chemistry in Ouy's Hospital 

MEDICAL JURISPRUDENCE. Seventh American Edition. Edited 

by John J. Reese, M.D., Prcf. of Med. Jurisp. in the Univ. of Penn. In one large 
octavo volume of nearly 900 pages. Cloth, $5 00 ; leather, $6 00. {Just Issued.) 

In preparing for the press this seventh American edition of the " Manual of Medical Jurispru- 
dence" the editor has, through the courtesy of Dr. Taylor, enjoyed the very great advantage of 
consulting the sheets of the new edition of the author's larger work, " The Principles and Prac- 
tice of Medical Jurisprudence," which is now ready for publication in London. This has enabled 
him to introduce the author's latest views upon the topics discussed, which are believed to bring 
the work fully up to the present time. 

The notes of the former editor, Dr. Hartshorne, as also the numerous valuable references to 
American practice and decisions by his successor, Mr. Penrose, have been retained, with but few 
slight exceptions ; they will be found inclosed in brackets, distinguished by the letters (H.) and 
(P.). The additions made by the present editor, from the material at his command, amount to 
about one hundred pages; and his own notes are designated by the letter (R.). 

Several subjects, not treated of in the former edition, have been noticed in the present one, 
and the work, it is hoped, will be found to merit a continuance of the confidence which it hag so 
long enjoyed as a standard authority. 

DY THE SAME AUTHOR. {Sow Ready.) 

THE PRINCIPLES AND PRACTICE OF MEDICAL JURISPRU- 

DENCE. Second Edition, Revised, with numerous Illustrations. In two large octavo 

volumes, cloth, $10 00; leather, $12 00. 
This great work is now recognized in England as the fullest and most authoritative treatise on 
every department of its important subject. In laying it, in its improved form, before the Ameri- 
can profession, the publisher trusts that it will assume the same position in this country. 

^Y THE SAME AUTHOR. New Edition— NowR^y. 

POISONS IN RELATION TO MEDICAL JURISPllUDENCE AND 

MEDICINE. Third American, from the Third and Revised English Edition. In one 
large octavo volume of SjO pages ; cloth, $o 50 ; leather, $6 50. 
This work, which has been so long recognized as a leading authority on its important subject, 
has received a very thorough revision at the hands of the author, and may be regarded as a 
new book rather than as a mere revision. He has sought to bring it on all points to a level 
with the advanced science of the day; many portions have been rewritten, much that was of 
minor importance has been omitted, and every efi'ort made to condense a complete view of the 
subject within the limits of a single volume. Dr. Taylor's position as an expert has brought 
him into connection with nearly all important cases in England for many years. He thus speaks 
with an authority that few other living men possess, while his intimate acquaintance with the 
literature of toxicology on both sides of the Atlantic, renders his work equally adapted as a 
text-book in this country as in Great Britain. 

Pot5o«5.— Absorption and Elimination— Detection— Action— Influence of Habit— Classifica- 
tion of Poisons— Evidence of Poisoning— Diseases resembling Poisoning— Inspection of the Dead 
Lody— Objects of Chemical Analysis— Moral and Circumstantial Evidence in Poisoning, &c. &c. 

Irnta?it Poiso?is.— Mineral Irritants— Acid Poisons— Alkaline Poisons— Non-Metallic Irri- 
tants—Metallic Irritants— Vegetable Irritants— Animal Irritants. 

Neurotic Po/«o>w.— Cerebral or Narcotic Poisons— Spinal Poisons— Cerebro- Spinal Poisons— 
Oerebro-Cardiac Poisons. 



Henry C. Lea's Publications — {Psychological Medicine^ d>c.). 31 



rpUKE [DANIEL BACK), M.D., 

J- Joint author of " The Manual of Psychological Medicine," &e. 

ILLUSTRATIONS OF THE INFLUENCE OF THE MIND UPON 

THE BODY IN HEALTH AND DISEASE. Designed to illustrate the Aotion of the 
Imagination. In one handsome octavo volume of 416 pages, cloth, $3 25. {Just Issued.) 
The object of the author in this vrork has been to show not only the effect of the mind in caus- 
ing and intensifj'ing disease, but also its curative influence, and the use which may be made of 
the imagination and the emotions as therapeutic agents. Scattered facts bearing upon this sub- 
ject have long been familiar to the profession, but no attempt has hitherto been made to collect 
and systematize them so as to render them available to the practitioner, by establishing the seve- 
ral phenomena upon a scientific basis. In the endeavor thus to convert to the use of legitimate 
medicine the means which have been employed so successfully in many systems of quackery, the 
author has produced a work of the highest freshness and interest as well as of permanent value. 



T>LANDFORD [G. FIELDING), M. D., F. R. G P., 

•*-^ Lecturer on Psychological Medicine at the School of St. George's Hospital, &e. 

INSANITY AND ITS TREATMENT: Lectures on the Treatment, 

Medical and Legal, of Insane Patients. With a Summary of the Laws in force in the 
United States on the Confinement of the Insane. By Isaac Ray, M. D. In one very 
handsome octavo volume of 471 pages; cloth, $3 25. 
This volume is presented to meet the want, so frequently expressed, of a comprehensive trea- 
tise, in moderate compass, on the pathology, diagnosis, and treatment of insanity. To render it of 
more value to the practitioner in this country. Dr. Ray has added an appendix which aft'ords in- 
formation, not elsewhere to be found in so accessible a form, to physicians who may at any moment 
be called upon to take action in relation to patients. 

It satisfies a want which must have been sorely actually seen in practice and the appropriate treat- 



felt by the busy general practitioners of this country. 
It takes the form of a manual of clinical description 
of the various forms of insanity, with a description 
of the mode of examining persons suspected of in- 
sanity. We call particular attention to this feature 
of the book, as giving it a unique value to the gene- 
ral practitioner. If we pass from theoretical conside- 
rations to descriptions of the varieties of insanity as 



ment for them, we find in Dr. Blandford's work a 
considerable advance over previous writings on the 
subject. His pictures of the various forms of mental 
disease are so clear and good that no reader can fail 
to be struck with their superiority to those given in 
ordinary manuals in the English language or (so far 
as our own reading extends) in any other. — London 
Practiti07ier, Feb. 1871. 



W: 



INSLOW [FORBES), M.D., D. G.L., Sfc. 

ON OBSCURE DISEASES OF THE BRAIN AND DISORDERS 

OF THE MIND; their incipient Symptoms, Pathology, Diagnosis, Treatment, and Pro- 
phylaxis. Second American, from the third and revised English edition. In one handsome 
octavo volume of nearly 6U0 pages, cloth, $4 25. 



EA [HENRY C). 

'superstition AND FORCE: ESSAYS ON THE WAGER OF 

LAW, THE WAGER OP BATTLE, THE ORDEAL, AND TORTURE. Second Edition, 
Enlarged. In one handsome volume royal 12mo. of nearly 500 pages; cloth, $2 75. 
{Lately Published.) 

interesting phases of human society and progress. . . 
The fulness and breadth with which he has carried 
out his comparative survey of this repulsive field of 
history [Torture], are such as to preclude our doing 
justice to the work within our present limits. But 
here, as throughout the volume, there will be found 
a wealth of illustration and a critical grasp of the 
philosophical import of facts which will render Mi. 
Lea's labors of sterling value to the historical stu- 
dent. — London Satv,rday Hnoiew, Oct. 8, 1S70. 



We know of no single work which contains, in so 
imall a compass, so much illustrative of the strangest 
operations of the human mind. Foot-notes give the 
authority for each statement, showing vast research 
and wonderful industry. We advise our confr&res 
to read this book and ponder its teachings. — Chicago 
Med. Journal, Aug. 1870. 

As a work of curious inquiry on certain outlying 
points of obsolete law, '"Superstition and Force" is 
one of the most remarkable books we have met with. 
— London Athenaeum, Nof. 'A, 1866. 

He has thrown a great deal of light upon what must 
be regarded as one of the most instructive as well as 



As a book of ready reference on the subject, it is of 
the highest value. — Westminster Review, Oct. 1867. 



B 



y THE SAME AUTHOR. {Late'y Published.) 

STUDIES IN CHURCH HISTORY— THE RISE OF THE TEM- 
PORAL POWER— BENEFIT OF CLERGY— EXCOMMUNICATION. In one large royal 
12mo. volume of 616 pp. cloth, $2 76. 

literary phenomenon that the head of one of the first 
American houses is also the writer of .^ome of its most 
original bouks. — London Atheaaium., Jan. 7, 1871. 

Mr. Lea has done great houor to himself and this 
country by the admirable works he has writleu on 
ecclesiologicaland cognate subjects. We have already 
had occasion to coinmoud his "Superstition aud 
Force" and hi.s "History of Sacerdotal Celibacy." 
The present volume is fully as admirable iu its me- 
thod nf dealing with topics and iu tlie thoroughness — 
aquality 80 frequently lacking in American authors — 
with which they are imrestigated. — A'. 1'. Journalof 
Psychol. Medicine, July, 1870. 



The story was never told more calmly or with 
greater learning or wiser thought. We doubt, indeed, 
If any other study of this field can be compared with 
this for clearness, accuracy, and power. — Chicago 
Examiner, Dec. 1870. 

Mr. Lea's latest Work, "Studies in Church History," 
fully sustains the promise of the first. It deals with 
three subjects — the Temporal I'ower, Benefit of 
Clergy, and Kxcommuuicatiou, the record of which 
has a peculiar importaucofor the Knglish student, and 
Is a chapter on Ancient Law likely to be regarded as 
final. We cau hardly pass from our mention of such 
works as these— wuh which that on "Sacerdotal 
Celibacy" should bo included — without noting the 



32 



Henry C. Lea's Publications. 



INDEX TO CATALOGUE. 



American Journal of the Medical Sciences 

Abstract, Half-Yearly, of the Med. Sciences 

Anatomical Atlas, by Smith and Horner 

Anderson on Diseases of the Skin 

Ashton on the Rectum and Anus . 

Attfield'g Chemistry 

Ashwell on Diseases of Females . 

Ashhurst's Surgery 

Barnes on Diseases of Women 

Bellamy's Surgical Anatomy 

Bryant's Practical Surgery . 

Bloxam's Chemistry 

Blandford on Insanity . 

Basham on Renal Diseases . 

Brinton on the Stomach 

Bigelow on the Hip 

Barlow's Practice of Medicine 

Bowman's (John E.) Practical Chemistry 

Bowman's (John E.) Medical Chemistry 

Brunton's Materia Medica 

Bnmstead on Venereal .... 

Bumstead and CuUerier's Atlas of Venereal 

Carpenter's Human Physiology . 

Carpenter's Comparative Physiology . 

Carpenter on the Use and Abuse of Alcohol 

Chambers on Diet and Regimen 

Chambers's Restorative Medicine 

Christison and Griffith's Dispensatory 

Churchill's System of Midwifery . 

Churchill on Puerperal Fever 

Condie on Diseases of Children . 

Cooper's (B. B.) Lectures on Surgery . 

CuUerier's Atlas of Venereal Diseases 

Cyclopedia of Practical Medicine . 

Dalton's Human Physiology . 

Davis' Clinical Lectures 

Dewees on Diseases of Females . 

Dewees on Diseases of Children . 

Druitt's Modern Surgery 

Dunglison's Medical Dictionary . 

Dunglison's Human Physiology . 

Dunglison on New Remedies 

Ellis's Medical Formulary, by Smith . 

Erichsen's System of Surgery 

Fenwick's Diagnosis .... 

Flint on Respiratory Organs . 

Flint on the Heart 

Flint's Practice of Medicine . 

Flint's Essays 

Flint on Phthisis . . . - . 
Fownes's Elementary Chemistry . 
Fox on Diseases of the Stomach . 
Falleron the Lungs, &c. 
Green's Pathology and Morbid Anatomj 

Gibson's Surgery 

Gluge's Pathological Histology, by Leidy 
Galloway's Qualitative Analysis . 

Gray's Anatomy 

Griffith's (R. E.) Universal Formulary 
Gross on Foreign Bodies in Air-Passages 
Gross's Principles and Practice of Surgery 
Guersant on Surgical Diseases of Children 
Hamilton on Dislocations and Fractures 
Bartshorne's Essentials of Medicine . 
Hartshorne's Conspectus of the Medical Sciences 
Hartshorne's Anatomy and Physiology 
Heath's Practical Anatomy . 
Hoblyn's Medical Dictionary 

Hodge on Women 

Hodge's Obstetrics 

Hodges' Practical Dissections 
Holland's Medical J^fotes and Reflections 

Holmes's Surgery 

Horner's Anatomy and Histology 
Hudson on Fevers .... 

Hill on Venereal Diseases 
Hillier's Handbook of Skin Diseases 
Jones (C. Handfield) on Nervous Disorders 



PAOE 

1 
3 



Kirkes' Physiology .... 
Knapp's Chemical Technology 
Lea's Superstition and Force 
Lea's Studies in Church History . 

Lee on Syphilis 

Lincoln on Electro-Therapeutics . 

Leishman's Midwifery .... 

La Roche on Yellow Fever . 

La Roche on Pneumonia, &c. 

Laurence and Moon's Ophthalmic Surgery 

Lawson on the Eye .... 

Laycock on Medical Observation . 

Lehmann's Physiological Chemistry, 2 vole 

Lehmann's Chemical Physiology . 

Ludlow's Manual of Examinations 

Lyons on Fever .... 

Maclise's Surgical Anatomy . 

Marshall's Physiology . 

Medical News and Library . 

Meigs on Puerperal Fever 

Miller's Practice of Surgery . 

Miller's Principles of Surgery 

Montgomery on Pregnancy . 

Neill and Smith's Compendium of Med. Science 

Neligau's Atlas of Diseases of the Skin 

Neligan on Diseases of the Skin . 

Obstetrical Journal .... 

Odling's Practical Chemistry 

Parry on Extra-Uterine Pregnancy 

Pavy on Digestion .... 

Pavy on Food 

Parrish's Practical Pharmacy 

Pirrie's System of Surgery . 

Pereira's Mat. Medica and Therapeutics, abridged 

Quain and Sharpey's Anatomy, by Leidy 

Roberts on Urinary Diseases . 

Ramsbotham on Parturition . 

Rigby's Midwifery 

Rodwell's Dictionary of Science . 

Swayne's Obstetric Aphorisms 

Sargent's Minor Surgery 

Sharpey and Quain's Anatomy, by Leidy 

Skey's Operative Surgery 

Slade on Diphtheria .... 

Smith (J. L.) on Children 

Smith (H. H.) and Horner's Anatomical Atlas 

Smith (Edward) on Consumption . 

Smith on Wasting Diseases in Children 

Still6's Therapeutics .... 

Sturges on Clinical Medicine 

Stokes on Fever 

Tanner's Manual of Clinical Medicine . 

Tanner on Pregnancy 

Taylor's Medical Jurisprudence . 

Taylor's Principles and Practice of Med Ju 

Taylor on Poisons . 

Tuke on the Influeuce of the Mind 

Thomas on Diseases of Females . 

Thompson on Urinary Organs 

Thompson on Stricture .... 

Thompson on the Prostate 

Todd on Acute Diseases .... 

Walshe on the Heart .... 

Watson's Practice of Physic . 

Wells on the Eye 

West on Diseases of Females 

Weston Diseases of Children 

West on Nervous Disorders of Children 

What to Observe in Medical Cases 

Williams on Consumption . 

Wilson's Human Anatomy . 

Wilson on Diseases of the Skin 

Wilson's Plates on Diseases of the Skin 

Wilson's Handbook of Cutaneous Medicine 

Winslow on Brain and Mind 

Wuhler's Organic Chemistry 

Winckel on Childbed 

Zeissl on Venereal .... 



nsp 



For " The Obstetrical Journal," Five Dollars a year, see p. 22. 



